jag 






c «j5^cc 






'■-- ^mCiccc 


: 








C </ c: ^C^C/C CC< r 


O <. vx «■_ « 


SI <<.-C«^ 


< ■ C. <• 




>. c< 


r ■ • c «^ 




c«c< 

re? 



■ <cc <:<r 


■ r < 


<^c CC ' 


« t. 


•ccc c c_ 


C( ( 


rcc • CTCL " 


i 


c «rc cc 




r - <« <r «: 




: <& CC ' 


Cf < 


Qt, «cc << 


< i 


<r ^ «?< «r«r 




C r cr CC 


c< 


C ci c «c 





«-- 


< C CCC C, v 


r 


cc ccr c 


5' 


C-C CC<- «j 


r" 


cc ccr <r 


r 


cc c<s c •-. 


r" 


CCCcrCv 


c 


<LC C<c 


c 


cc cc c 


c 


(C CC c 


c 


cc cc c: 


V < 


tl".C CC C 


• i_ 


C C CC c 


' C 


*w V vV C 


.; <r 


C_C cc:<; 




,- C C CC 



«1CC c 



CC 


<• - <• <s c 


c< 


C CO. C 


c_«l 


« < 


CC 


< < 


^c 


<C ' < c 


<c ■ 


K S^ * 


cc 


c C 


3 v.« 


Z <• i 


< 


c 


L' '« 


c 



'Ilibrary of congress, 



#|^i> ferinhi ;\o. 



JM*jf:jd:i.^ | 

— # 

J UNITED STATES OF AMERICA, fj 






•C C^ CBf'C'CC- <*C< '< 



4TI <? CC «£C C C 



«r ««=<?-«: 



cccc 4sr 



<c^^ 















PRINCIPLES OF MEDICINE: 



COMPRISING 



GENERAL PATHOLOGY AND THERAPEUTICS, 



AND A BRIEF GENERAL VIEW OF 



ETIOLOGY, NOSOLOGY, SEMEIOLOGY, 
DIAGNOSIS, AND PROGNOSIS. 



CHARLES jf B^WILLIAMS, M.D., F.R.S., 

Fellow of the Royal College of Physicians; 

Professor of the Principles and Practice of Medicine, and of Clinical Medicine, 

And First Physician to the Hospital, University College, London; 

Consulting Physician to the Hospital for Consumption 

And Diseases of the Chest, &c. 



AVITH ADDITIONS AND NOTES BT 



MEREDITH CLYMER, M.D., 

Lecturer on Uio Institutes of Medicine; Physician to the Philadelphia Hospital; 
Fellow of the College of Physicians, &c, &c. 







' 



PHILADELPHIA. 
LEA AND BLANC HARD 
1 8 4 4. 



W 






^ 



Entered according to the Act of Congress, in the year 1843, by 

LEA & BLANCHARD, 

in the Clerk's office of the District Court of the United States in and for the 
Eastern District of Pennsylvania. 



&4a 



T. K. & P O. COLLINS, PRINTERS. 



LC Control Numbei 



tmp96 028695 



PREFACE 



As an apology for the appearance of this publication, it may, 
I think, be stated to be generally acknowledged, that there is at 
present no work which fully treats of the subject of General 
Pathology, and its application to practical medicine. The present 
attempt to supply the defect arose from my feeling the want of 
an elementary work on these subjects, by aid of which I could 
introduce to my pupils the science of practical medicine. With 
many excellent and elaborate treatises on the details of medicine, 
we have scarcely any which treat of those general principles in 
the nature and treatment of disease, which are really fundamental 
in the practice of medicine. Even the very able work of my 
distinguished friend, Professor Alison, (to which the following 
pages owe much,) in the last edition, instead of some of these 
general principles, embraces some of the details of Special Patho- 
logy. 

It may be supposed, that in subjects comparatively so modern 
as those embraced in this work, little reference can be made to 
any but recent authors; and for a great portion of the facts and 
illustrations, I have drawn on my own experience in the continual 
observation of disease, during upwards of twenty years, in hos- 
pitals and private practice. Throughout this experience, I have 
always endeavoured to keep in mind the bearings of physiology 
and pathology on practical medicine, and to render their advances 
useful, by their application to this art. Many original facts and 
opinions have been the result of this mode of study; and some 
of these will be found in the following pages. I cannot expect 
that they will speedily receive ;i general assent; but I ask for them 



IV PREFACE. 

the test of clinical observation, from which they have been mainly 
derived. 

It seems quite extraordinary that, notwithstanding the recent 
rapid improvements and comparative perfection of the contribu- 
tory sciences, practical medicine should still halt in the domain of 
empiricism. A chief reason for the anomaly seems to be, that 
science and practice have been rarely pursued by the same 
parties. Scientific men are not and cannot be practical, because 
they have had no experience; and practitioners know little ot 
science, and therefore derive little good from it. Instead of work- 
ing together, these parties are at issue with each other. But it is 
high time to put an end to this feud. Philosophers must descend 
from their transcendental positions, to consider the details of prac- 
tice and purposes of utility. Those who would be practitioners, 
must gain from science that knowledge and that method which 
render experience instructive and useful. 

In the present effort towards the accomplishment of these 
objects, I am conscious of many deficiencies. Want of time has 
prevented me from treating some subjects as fully as they deserve, 
particularly those of the last chapter. In others, I have studied 
to be brief, to avoid perplexing the reader with much discussion 
or detail. For tins reason, doubtful facts and a variety of con- 
flicting opinions have been withheld; and only the facts best 
ascertained and the views which seem most tenable have been 
given. By tins eclectic method, I have succeeded in reducing 
a very extensive range of subjects within the compass of a mode- 
rate volume. 



7, Holies Street, Cavendish Square, 
22 Sept. 1843. 



PREFACE TO THE AMERICAN EDITION. 



A work on General Pathology supplies an actual want in 
English Medical literature. Dr. Williams is so favourably known 
in this country, more particularly by his treatise on the Diseases 
of the Chest, that his name is almost a sufficient guaranty for the 
excellence of the present work. These expectations will not be 
disappointed. Owing to the want of time on the part of the 
Author, several subjects have not been fully treated of. To supply 
these omissions has been the endeavour of the American Editor. 
The chief additions will be found in the Sections on the Blood, 
on Diagnosis, and on Prognosis. A chapter on Fever, and one 
on Hygiene have also been added. The new matter is distin- 
guished thus [ — C.]. The Editor must here state his acknow- 
ledgments to the works of Professor Alison,* ChomeLt and An- 
dral,t to which he has had occasion to make frequent reference. 

M. C. 

. * Outlines of Pathology and Practice of Medicine. By William Pulteney 
Alison, M. D., Edinburgh, 1843. 
f Etemens de Pathologie G6nerale. Par. A. F. Chomel. Paris, 1841. 
t Essai d'Hematologie Pathologique. Par G. Andral. Paris, 1843. 



230, Spruce Street, 
22 Nov. 1843. 



CONTENTS 



Preface p. iii 

Preface to the American Edition p. V 

Introductory Lecture on the Need of the Study of General Pathology as 
the Foundation of Practical Medicine. 

State of Practical medicine as a study and as an art. Favour shown 
to empiricism by the public. Irksome and difficult character of 
the study of medicine as usually taught. Insufficiency of empirical 
and nosological medicine. Some knowledge of general pathology 
at length gained in practice. Need of general pathology in the 
study and practice of medicine. What is general pathology? 
Contributions from all departments of medical science, especially 
clinical medicine. General pathology the proper introduction to 
special pathology. Where principles fail, experience must be the 
sole guide. Noble nature and objects of medicine the best en- 
couragements to its careful study - - - - p. 13 — 28 



Paragraphs 



PRINCIPLES OF MEDICINE. 

Explanation of the Subjects of the Work - - - p. 29 

1, 2 Principles of medicine- synonyms; whence derived. Etiology, pa- 

thology proper, principles of treatment - - - - p. 29 

4. Other subjects stated. 

Definition of disease p. 30, 31 

6 Standard of comparison. Definition of health. Deviations from 

V health: in function; in structure. Physiology the standard of 

healthy function; anatomy, of healthy structure. 

8 Definition of disease. 

9 Variations in the standard of health. 



CHAPTER I.— ETIOLOGY— ON THE CAUSES OF DISEASE. 

Section I. — Nature and Division of Causes - p. 32 — 35 

10 Causes of disease intrinsic and extrinsic. Causes of disease not 

11 sure in operation; except those which are very strong. They 

12 generally require predisposition. Examples. 

13 ('hum- divided into ivnidir and nmximatr. Kcniolc divided into 

14 predisposing and exciting. Co-operation of predisposing and ex- 

15 citing causes generally necessary. Examples. Exceptions. 



CONTEXTS. 



Paragraphs „ . . _ 

16 Predisposition generally absence of natural resisting power. Ex- 

17 amples of the operation of this resisting power. 

18 Predisposition from error of structure. Other names of predisposing 

19 causes. 

Section II. — Predisposing Causes of Disease - - p. 35 — 43 

20 Exemplification of predisposing causes. Debilitating causes. Imperfect 

21 23 nourishment. Impure air. Fatigue of body or mind. Heat with 

24 26 moisture. Continued cold. Habitual intemperance. Depressing 

27 29 passions. Excessive evacuations. Previous disease. 

29, 30 Vascular fulness or activity. Previous disease operating by change of 

31 33 structure; by persistence of cause. Examples. 

33 — 35 Organic disease already existing. Innate predispositions. Hereditary 

36 — 40 tendency. Temperament: sanguine, bilious, phlegmatic, nervous. 

41 44 Diathesis. Age.- infancy, childhood, puberty, full-growth, adult age, 

45 — 48 old age, exemplified in vascular and nutritive functions. 



49,50 

51 

52 

53 

54—56 

57,58 

59,60 

61—62 

63 

64 

65 

66 

67 



70 

71 

72, 73 

74,75 

76 

77 

78 

79 



81, 


82 


83, 


84 


85 




Ml. 


87 


B8 




89, 


90 


91, 


92 



8b( ii hn III. — Exciting Causes of Disease 



p. 43—60 



Operation of exciting causes. Division into cognizable and non- 
cognizable. 
I. Ciii.mz vi'.i.r. Agents. (1.) Mechanical causes: examples of their 
physical effects. Vital operation of severe injuries. (2). Chemical 
causes: extrinsic, intriii 

(3.) Ingesta. Non-alimentary; examples; intoxicating liquors, 

abuse. Adulterations of food. Medicines. Aliment ill propor- 
tioned: adue mixture requisite. Simpl< luch as sugar, 
gum, &c, insufficient. Bread the stall' of life. Liebig's views on 
aliments. Dr. Proul's. Results of familiar experience. Excessive 
aliment. Defective aliment. 

(4.) Violent exertion: effects on heart, brain, lungs, &c. Partial exer- 
tion. Exhaustion from fatigue. 

(5.) Strong mental emotion. Slow emotion. Continued mental exertion. 

(6.) Retention, diminution, and suppression of evacuations, alvine, 
urine, &c. L"\ver degrees common in disease. Suppn 
artificial discharges, cutaneous eruptions, &c. 

(7.) Excessive evacuation. Effects. Syncope, cerebral and cardiac. 
Other effects and resulting diseases. 

(8.) Temperature and changes. Extreme heat and cold; local effects. 
Constitutional effects of burns; of extreme cold. Stimulant opera- 
tion of heat: view of Liebig. Partial heat. Operation of moderate 
cold. Indirect effects of cold in the part chilled. Operation of 
external cold on internal parts. Cause of" catching cold," by dis- 
ordering circulation. Symptoms of "cold caught" Susceptibility 
to cold. Means of diminishing it. Cold bathing. Water cure. 



Section IV. — II. Non-cognizable Agents 



60—68 



93, ! 



Definition and division into endemic, epidemic, and infectious. 

I. Endemic causes. Proofs of their existence. Sources. Malaria. 
Nature of malaria. Its properties. Sources of malaria. Its viru- 
lence in proportion to heat with moisture. Morbid effects of malaria. 
Kinds of malaria. Endemic diseases from cognizable causes. 

II. Epidemic causes. Proofs of their existence. Epidemic. Cognis- 
able causes distinguished from non-cognizable. Epidemic consti- 
tutions or periods. Nature of epidemic influences. Dr. Prout's 
observations. Animalcule origin of epidemic diseases. 

III. Infectious causa. Proofs of their existence. Modes of infection. 



CONTENTS. IX 

Paragraphs 

94 — 97 By wounds. By contact. By aerial communication. By several 

98,99 modes. Difficulties of explaining infection. Analogy of fermenta- 

100 tion; of animal and vegetable generation; examples. Parasitic 

view of infection confirmed by circumstances which promote and 

check it. 
101 — 103 Peculiarities of infectious diseases: of endemic; of epidemic. 

104 Diseases propagated in several-ways. Pestilences. 

105 General operation of all these causes depressing. 



CHAPTER II.— PATHOLOGY (PROPER) OR PATHOGENY. 

106 Disease composed of elements. Analogy with chemistry. Primary 

107 elements of structure and function; healthy and diseased. Proxi- 
108, 109 mate elements of disease. These elements the proper subjects of 

general pathology and therapeutics - - - p. 69, 70 

FUNCTIONAL DISEASES.— PRIMARY ELEMENTS. 

Section I. — Diseased Irritability - - - . p. 71—74 

110 — 115 Natural irritability. In excess. Varieties: in strength; in mobility; 

in duration. ■ Remedies for excessive irritability. 
116, 117 Defective,- in force; in mobility. Connection of irritability with nerves 
118,119 not essential. Remedies for defect. 

Section II. — Diseased Tonicity p. 74 — 77 

120 Natural tonicity: distinct from irritability; proved by different effects 

of cold and heat. Long known empirically. 
121, 122 Excessive. Examples. Remedial measures. 
123, 124 Defective. Examples. Atony. Remedial measures. . 

Section III. — Diseased Sensibility ... p. 77 — 82 

125 Sensibility referable to nervous system, and divided into general and 

local. 
126 — 128 General. Excessive.- from disease; from temperament. Pathological 

causes. Remedies. 
129, 130 Defective. Causes: from disease; temperament. Remedies. 

131 Perverted. Examples; causes; remedies. 

132 Local sensibility. Variations illustrated by experiment. 
133 — 136 Pathological causes. Excessive.- in orifices, pain, &c. 
137,138 Defective. Remedies for diseased local sensibility. 

Section IV. — Diseased Voluntas Motion p. 82 — 86 

139 Division into general and partial. 

140 General voluntary motion: in Excess,- Examples. 
141, 142 Defective.- Examples. Perverted.- Examples. 

143, 144 Partial. Excessive.- rare. Defective.- causes. Examples. 
145 — 147 Remedies for excessive voluntary motion; for defective local. Per- 
verted. 

Bsci ,, lN V. — Diseased Reflex and Sympathetic Neiiych s 

I.NFLUKNCE p. 86— 92 

148 — 153 Natural reflex function. Excessive.- in involuntary muscles; in volun- 
tary muscles. Convulsions, centric and eccentric. Partial, by 



X CONTENTS. 

Paragraphs 

reflected irritation. Irritation of involuntary muscles. Patho- 
logical causes of inordinate excitomotion: from poisons; from rest 

154,155 Defective reflex motion. In coma; asphyxia; sinking, &c. Remedies 
for excessive. Narcotics. Sedatives, stimulants. Tonics. 

156,157 Reflected or sympathetic sensations. Examples. Remedies. 



Section VI. — Diseased Secretion 



- p. 92— 100 



158 — lbO Secretion due to a vital property, aided by chemical affinity. Changes 
due to altered supply of blood, or to nervous influence. 

161 — 166 Division. Excessive. Effects: forwards; backwards; on the organ; 
on the blood. Examples. Remedies. Depletion. Astringents. 
Alteratives. 

167 — 175 Defective. ('au<es. Effects: forwards; backwards. Extreme; mo- 
derate. Remedies: through the circulation. Specific stimulants. 
Alteratives. Tonics. Substituti ctive secretion. 

176,177 Perverted secretion. Examples. Effects. Remedies. 

Diseases of the Constituents of tut. Blood - - p. 100, 101 

179 Constituents of the blood diseased constitute elements of disease. 

180 Enumeration of constituents ami modes of di 

181, 182 Changes of the entire blood. Chemical composition of blood. 



Section VII. — Diseases of Red Pah ik lbs 



p. 102—106 



183 — 193 Natural offices and proportions. Excess. Examples and effects. 
Defect. Examples and effects. Alterations.- in colour; in size and 
form. Arterial change. Structure. Spontaneous motion? .Mr. 
W.Jones's observations and explanation. Origin of red particles. 
Remedies. Excess. Defect. 



Section VIII. — Fibrin and White Clobcles 



p. 107—118 



194 — 205 Nature of fibrin. Purposes. Excess. Examples. Increase of white 
globules. Defect. Examples in fluidity of blood. Ca 
haemorrhage; congestion. Alterations in quality: apparent from 
chara* ulurn, which shows properties of self-coagula- 

tion, contraction, and sepafatii dation: varieties and 

causes. Contract: and causes. Separation: causes. 

Varieties. Causes of buffy coat. 

206 — 213 Appearances of coagulated blood.. Large clot. Small clot. Sepa- 
rated and cupped. Mode of exhibiting these properties. Source 
of fibrin. Increase by inflammation. Material of coagufable 
lymph. Varieties. White globules. Coagulation of fibrin 
life: vegetations and polypi. 

214 — 216 Remedies for excess of fibrin. Blood-letting. Evacuants. Diet, &c. 

216 Remedies for defect: diet: regimen; tonics; antiseptics, &c. 

217 — 219 Means of altering quality of fibrin. Depletion. Alteratives. Tonics, 
&c. 



220 
221,222 



223, 224 



Section IX. — Albumen 
the Sercm - 



m other Animal Principles 



p. 118, 119 

Natural proportions and offices of the albumen. 

Excess. Examples. Causes. Remedies. Defect. Examples. Effects. 

Section X. — Oil or Fatty Matter - - - - p. 119 

Excess. Milky serum. Cases. Source of fat. Causes of obesity. 



CONTENTS. 



XI 



Paragraphs 

Section XI. — Saline Mattes. - - - - p. 120 

225 — 227 Excess. Thirst caused by salt. Defect in yellow fever and cholera. 
Effect of saline injections. Effect of salt in preserving the red 
particles. 



Section XII. — Water 



122 



p. 121, 

228—231 Excess. Examples and effects. From too much drink. Defect. 
Examples. Symptoms. Causes. Effect of abstinence from li- 
quids. Remedies for excess and defect. Dry diet and water cure. 

Section XIII. — Changes in the Blood bt Respiration p. 122 — 128 
Analysis of the Changes. Excess. Examples in disease? 



232, 233 
234—244 



Defect; the element of asphyxia. Effect proportioned to suddenness 
as well as degree. Analysis of asphyxia. Classification of symp- 
toms. Defect gradually induced. Hybernation. Cyanosis: state 
of functions. Little muscle and much fat, with defective respira- 
tion. Remedies for defect: lowering functional activity. Stimu- 
lants. Promoting respiration. Other means of arterializing the 
blood! 
243 — 244 Treatment of the congestion of apnoea. Diet in dyspnoea. 

245 Excess of changes by respiration: in rheumatism] Respiration of 

246 oxygen gas. Effects explained. Liebig's notion of action of hy- 

247 drocyanic acid controverted. 

Section XIV. — Changes in the Blood bt Secretion p. 128 — 130 

248 Defective secretion of urine. Experiments of Prevost and Dumas. 
249,250 Effect of diseased kidneys. Of bile. Examples; effects. Defect- 

251 - ive perspiration; Vicarious action of skin and kidneys. Rheu- 

252 matism. Remedies to be directed to this element. 



Section XV. — Changes in the Blood from the Transformation 
of Chyle and of the Textures - - - - p. 130 — 134 

253 Natural changes uncertain. Lithic acid diseases. Causes. 

254 Morbid effects on kidneys. Gout. Varieties. Effects. 

255 Formation of sugar in diabetes. Effects and treatment in gout and 
256,257 diabetes contrasted. Production of urea in excess. Remedies. 



258, 259 
260 



Section XVI. — Changed Properties of Blood from the presence 
of Foreign Matters - - - - - p. 134 — 136 

The blood the seat of morbid poisons: proofs: and of germs of ma- 
lignant disease. Treatment of morbific matters in the blood. 



CHAPTER III.— PROXIMATE ELEMENTS OF DISEASE. 



Section I. — Antemta 



137—145 



261 
262, 
204, 



270, 
272 
273 



Explanation of proximate elements of disease. 
263 General ansemia. Nature and symptoms. Physical signs. Changes 
265 in the blood. Symptoms of excitement in ansemia. Explanation of 

267 these symptoms. Symptoms of coma, &c. Cases and interpreta- 

269 tion of nature of anajmic coma. Nutrition in anaemia. Exciting 

271 causes of anasmia. Fatal terminations. Remedial measures. 

Regimen and diet. Medicines. 

Partial anaemia. Examples. Effects. 



CONTEXTS. 



Paragraphs 



Section II. — Htper.bmia, on Excess of Blood p. 145 

Definition and nature. Classification of varieties. 



Section III. — Plethora — General Excess of Blood p. 146 — 150 

275—278 Origin of plethora. Subjects. Symptoms. Tendencies. Causes. 
279, 280 Division into sthenic and asthenic. Symptoms of sthenic. Subjects. 

281, 2S2 Asthenic. Symptoms. Subjects. Results. Fever, Gout, &c. Re- 

.283,284 medial measures. Blood-letting: where unlit. In sthenic, other 

285, 286 measures needed. In asthenic, tonics as well as evacuants. 

Local Htper.t:mia. Excess of Blood ih a part. 

Section- IV. — With Motiok diminished - - p. 150 — 165 

287, 288 Congestion analyzed. Its causes classed. 

289 Congestion from venous obstruction. Examples in health and disease. 

290 Congestion for atony of the vessels. Prom general debility; hypostatic 
291,292 From <■ a. Examples. From intropulsive action of cold 
293,294 and of malaria. From previous excitement or inflammation. Ex- 
295,296 amples and illustration by microscope. From direct operation of 
297,298 cold. From arrest of secretion, or of capillary circulation. Atony 
299,300 of vessels impedes transit of blood. Experiments to show neu- 

301 tralizai I ntinuance 

302 of congestion. 

303,304 Symptoms and effects of congestion* Effects on plained. 

305 Production of flux. Examples. Amount oft i [ualityof 

306 — 308 blood determine quality of effusion, liquid and solid. Albuminuria 

309 referred to congestion of the kidney. Reasons. Congestion con- 

310, 311 tinning, causes hypertrophy of a peculiar kind. Origin of granular 

312 disease and cirrhosis. Other instances. 

313 Remedies for congestion. Removal of causes. Venous obstruction 

314 and causes o sure. Friction. Exercise. 
315, ol6 Astringents and tonics. When inapplicable. Stimulanl remedies. 

317 Operation shown by the i When hurtful. Depletion 

318 and other evacuants. Preceding remedies properly combined or 
319,320 alternated. Prevention of c< 

Section V. — LociiHrPER.EMiA,on Excess of Blood in a twit, WTFH 
Motion increased — Determination of Blood p. 165 — 176 

Examples in health. In disease. Determination to the head. Ex- 
amples, with symptoms. Caused by stimuli. Physical cause of 
determination of blood. Enlargement of arteries proved by experi- 
ment and microscope. Causeof the enlargement alo^s of tonicity. 
Opinions refuted. Final cause of determination to supply more 
blood where wanted. Determination by intropulsion. Subjects of 
local determinations. Determination may cause anaemia in other 
parts. Determination affects large an 

Symptoms and effects of determination. To the head. Explanation of 
the remarkable difference in different cases. To the kidneys. To 
mucous membranes. To the skin. Other symptoms. Deter- 
mination if continued causes hypertrophy. 

Remedies. Removal' of causes. Means to promote contraction of 
dilated arteries. Cold. Astringents. Derivants. Posture. Eva- 
cuants. Blood-letting; general and local; its effect seen in the 
microscope. Remedies to relax the arterial system, and quiet the 
heart. Measures to equalize and strengthen the circulation. Tonics. 



321, 


322 


323, 


324 


325, 


326 


327, 


328 


329 




330 




331 




332 




333- 


-335 


336 




337- 


-339 


340, 341 


342, 


343 


344, 


345 


346 




347, 


348 


349 





CONTENTS. Xlll 

Paragraphs 

Section VI. — Results of Hyperemia p. 176 — 200 

350 Hemorrhage, flux, and dropsy, results short of inflammation. 

351 Hemorrhage from plethora. Examples. Epistaxis, hematemesis 

352 &c. from congestion of venous obstruction. Examples: pulmonary, 

353 bronchial, gastric, &c. From atony of vessels; from posture; from 

354 intropulsion of cold. Examples. From determination of blood. 

355 Examples; epistaxis, hematuria, apoplexy, &c. Additional ele- 

356 ment of haemorrhage in the vessels or in the blood. Blood-vessels 
357, 358 diseased: examples. Blood diseased; hemorrhagic diathesis. Mode 

359 in which blood is effused, by rupture or through pores. Varieties 

360 of hemorrhage. Sthenic and asthenic denned. 

361, 362 Symptoms of hemorrhage. Molimen haemorrkagicum. Faintness. 

362 — 364 Reaction. Transition to inflammation. Examples. Local effects 

365 and symptoms. Passive hemorrhage. 

366, 367 Treatment of hemorrhage. Remedies for hyperemia. Styptics. 

368 — 370 Active or sthenic. Passive or asthenic. Mechanical means. 

371, 372 Special styptics. Tonics. Derivants. 

373,374 Flux and Dropsy. From plethora. Examples. 

375 From congestion. Experiment of Lower. Examples in disease. 

376 — 378 From weakness of vessels. After excitement. Intropulsion of cold. 

379,380 From determination of blood. Examples; active flux; active dropsy. 

381, 382 Flux and dropsy vicarious. Examples. Circumstances causing 

383 hyperemia to lead to these results: in the vessels: in the blood. 

384 Diseased blood from defective excretion, especially by the kidneys. 

385 Examples and proofs. Dropsy and flux with albuminuria: why 

386 inflammatory: resemblance to rheumatism. Thinness of the blood, 

387 cause of asthenic dropsy. Dropsy from retention of water and ex- 

388 crementitious matter in the blood. Malnutrition. Proofs. Dis- 

389 tinctive pathology of flux and dropsy. Causes of each. 

390 General treatment of flux and dropsy. Remedies for hyperemia. 

391 Remedies for malexcretion and malnutrition. 

392, 393 Treatment affluxes. Derivants. Removal of causes. For sthenic 

394 flux. For asthenic: astringents, tonics. Dry and tonic regimen. 

395 Treatment of Drops;/. Means to remove effusions, and restore action 

396 of kidneys in sthenic dropsy. Means to improve the blood in 

397 asthenia. Recurrence of dropsy requires variation of remedies. 

398 Examples. Circumstances which indicate tapping or puncture. 
Cautions. 

Section- VII. — Local Hyperemia, Excess of Blood in a part, 
with Motion partly increased, partly diminished — Inflam- 
mation - p. 200 — 280 

399, 400 Inflammation not understood from not studying its elements. Defini- 
tion, by nature; by signs. 

401 Causes of inflammation and mode of operation. Predisposing. 

402 Exciting divided into director local, and indirect or general. Local 

403 irritants, mechanical, chemical, and vital. Indirect cause produce 
404, 405 congestion. Causes mixed in operation. Checked hemorrhage 
406 and flux. Irritants operate first on nerves. But inflammation 
407, 408 sometimes excited without nervous irritation. Cause essentially 

acts on vessels, sometimes producing congestion first, sometimes 
determination. 

409 Phenomena and nature of inflammation. Difference from con- 

410 gestion. Essential characters established. Increase of blood with 

411 motion increased and diminished. Cause of the obstruction. Views 

412 of Cullen, Hunter, W. Philip, Alison, considered. Examination 

413 of incipient inflammation with the microscope: descriptions. Atony 



XIV CONTENTS. 

Paragraphs 

414 of the vessels a partial cause of obstruction: examples and experi- 

415 merits. Another cause within the vessels: adhesion of white glo- 

416 bules; their increase. Description and production of white glo- 

417 miles. Messrs. Addison and Gulliver's observations. Adhesive 

418 property of white globules examined. Their presence and pro- 

419 perties essential to inflammation. Conclusions as to obstruction 

420 of inflammation. Effect of obstruction to direct force on arterial 

421 capillaries. This opposition of obstruction to force also the cause 
of destruction. 

422, 423 Effects of inflammation on vital properties. Effusions; general cha- 

424 racter; microscopic character. Exudation corpuscles. Elementary 

solids of inflammatory effusions. Molecules. Granules. Fibrils. 

425,426 Lymph corpuscles. Pus globules. Tubercle. Mode of formation 

427 of some of these. Other effecs of inflammation. Softening. Sup- 
puration. Slough. Gangrene. Induration. 

428 Stmptoms axd effects of ixflammatiox. Division into local and 

general. 
429,430 Local symptoms. Redness,- cause; varieties and causes; changes. 
431, 432 Heat; cause; indications. Swelling; causes; varieties from texture. 
433,434 Pain,- causes. Degrees and varieties, and their causes. Other 
435,436 sensations. Effect of inflammation on contractility. On other 

functions and symptoms. 

437 Coxsti n thin u. Symptoms. Inflammatory fever. Change in the 

438 blood. Cause of the increase of fibrin, and its more contractile 
439,440 property. This not the 'cause of in flami er with an irri- 
441,442 ration or reaction. Symptoms of inflammatory fever. Its varie- 
443,444 ties. High, low. Type of fever from cause or seat of inflamma- 
tion. Remittent and intermittent fever. No fever. 

Natciie axd Soiptoms of Results of Terminations of Inflammation. 
445_447 Division. Resolution. Its nature. Modes of occurrence. 

448 symptoms. Constitutional symptoms of resolution. Lateritious 
sediments; cause, &c. 

449 Effusion (including adhesion.) Not always a termination. History 

450 of effusions in serous memorant s. Coagulable lymph. Varieties. 

451 Euplastic. M nization. Formation of vessels. Caco- 
452 — 454 plastic lymph; varieties and effects. Aplastic lymph. Causes of 

455 these low products. Effusion of mucous membranes. Int< 

456 deposit. Changes of mucus. Effusion in skin.- varieties of cuta- 
457 — 459 neons inflammation. Effusion in cellular texture. \x\ par enchy mala. 

Symptoms of effusion. 
460 Suppuration and ulceration. Nature of pus; microscopical charac- 

461,462 ters. Its want of cohesion. Causes of suppuration. 1. Intensity 

of inflammation. 2. Access of air. 3. Condition of the blood. 

463 Pus in the blood] Process of suppuration explained: absorption 

464 of all but pus globules. Varieties of suppuration. Diffused. Ab- 
465,466 scess: pyogenic membrane: pointing. Opening and healing of 
467,468 abscesses. Granulation. Ulceration. Varieties. Causes. Soften- 
ing of textures. Suppuration a work of destruction, therefore 

469 depressing. Symptoms of suppuration. Local: constitutional: 

470 varieties caused by limitation, or not, of suppuration. Purulent 

471 deposits. Nature and causes. Possibility of absorption of pus. 

472 Depression from suppuration. Hectic fever. Varieties of pus: 
laudable: ill-conditioned. 

473 Gangrene. Process of sloughing; gangrene: sphacelus. Causes of 

474 gangrene: interrupted circulation: noxious agents. Local symp- 

475 toms and effects of gangrene: constitutional symptoms. Combina- 

476 tions and gradations of the results of inflammation. 



Paragraphs 



CONTENTS. 



Varieties of Inflammation. 



477 Sthenic and asthenic. Symptoms: results. 

478 Acute inflammation. Subacute: symptoms: products. 

474 Chronic inflammation. Symptoms: duration: products and results. 

480 Congestive inflammation: nature: symptoms: results. 

481 Phlegmonous inflammation: nature: causes: type and symptoms. 

482 Erythematic and erysipelatous: local symptoms and effects: fever: 

483 cause specific. Pellicular.- asthenic: symptoms: low fever. Plastic 
inflammation of mucous membranes. Aphthous inflammation. 

484, 485 Nsemorrhagic inflammation; causes. Scrofulous inflammation; as- 

thenic; peculiar symptoms. Scrofulous diathesis; its external 
marks: its symptoms and causes. Course and results of inflam- 
mation in scrofulous subjects. Condition of the blood. Gouty and 

486 rheumatic inflammations. Nature and causes. Gonorrhceal in- 

487 flammation; seat and effects. Syphilitic inflammation; seat and 
effects. 

488 Treatment of inflammation, best understood from knowledge of 

its elements, and of counteracting measures. 

489 Tabular view of constituents of inflammation. ■ 

490 Tabular view of chief elements of inflammatory disease and their 

491 remedies. Comments on the principles of antiphlogistic treatment. 

492 Remedies: 1. for congestion,- 2. and 3. for irritation of nerves and 
493, 494 vessels,- 4. for determination to the part; 5. and 6. for obstruction in 

the part, by atonic enlargement of capillaries, and adhesion of 
495, 496 white globules; 7. for distension of vessels; 8. for effusions from the 

497, 498 vessels; 9. for increased absorption,- 10. for impeded circulation in 

499 the part. For the increased circulation around the obstructed 
part. 

500 Treatment of inflammation with fever. Local remedies secondary. 

501 Chief remedy, general blood-letting,- effect; tolerance in inflamma- 

502 tion; cause. Objects, and modes of blood-letting: in recent in- 

503 flammation; in confirmed inflammation; in inflammation with 
504, 505 plethora. Local blood-letting: uses. Evacuants: purgatives; com- 

506 binations. Tartarized antimony: modes of exhibition: mode of 

507 operation. Mercurj*: calomel and opium: modes of exhibition: 
508, 509 operation. Refrigerants. Salines. Diuretics. Sedatives. Counter- 
510,511 irritants. Treatment of exhaustion. Depression from poison. 
512 Solid effusions. Antiphlogistic regimen and diet. 

Treatment of Varieties of Inflammation. 
513 — 517 Sthenic. Asthenic. Acute. Subacute. Chronic. Congestive. 

516 (bis) Phlegmonous. Erysipelatous. Pellicular. Hemorrhagic. Scro- 

517 (bis) fulous. Treatmentof scrofulous diathesis. Rheumatic and Gouty. 
519, 520 Gonorrhceal and syphilitic. 

[Section VIII.— Idiopathic Fever. {Dr. Clymer.) - p. 280—287 

Fever independent of any local affection. Reasons for regarding 
fever as distinct from the constitutional effects of inflammation. 
Symptoms. Causes. Morbid appearances. State of the blood. 
State of the spleen, {note.) 

The Pathology of Fever. 

Is the nervous system or blood primarily affected! Local complica- 
tions of fever. The nervous system. The respiratory organs. 
The abdominal viscera. The terminations of fever. 



XVI CONTENTS. 

Paragraphs 

Treatment of Feter. 

Natural tendency to favourable termination. Cannot be cut short. 
Patient must be placed under favourable circumstances. Type of 
epidemic. Evacuants. Diet. Convalescence.] 



OHAPTER IV.— STRUCTURAL DISEASES; OR DISEASES OF 
NUTRITION. 

Section I. — Nature and Classification - - - p. 288 — 291 

521 Arrangement of structural disease. Table of elements. Structural 

522 disease. Modifications of natural nutrition. Material of nutrition: 

523 fibrin. Modes and process of nutrition. Variations in nutrition. 

524 Causes. Relation to nervous influence. 

Section II. — Increased Nutrition — Htfertrophy p. 291 — 293 

525, 526 Varieties. Simple hypertrophy; of muscles. Examples of intersti- 

527 tial textures. Of epidermis: varieties in skin diseases. Complex 

528 hypertrophy: Uterus; breasts; brain; follicles; bursas, &c. Liver 

529 and spleen. Treatment of hypertrophy. 

Section III. — Di mi msued Nutrition — Atrophy - p. 293 — 296 

530 Atrophy may be general. Emaciation. Causes. Drains. Causes 

531 preventing reparatory nutrition. When traced to its cause an im- 

532 portant sign. Partial atrophy, from defective supply of blood. 
533, 534 Examples. Treatment of atrophy: general,- partial. 

PERVERTED NUTRITION. 
535 Alterations in kind; in texture - - - - - - p. 296 

Section IV. — Induration and Softening. - - p. 296 — 299 

536, 537 Both may be independent of inflammation. Nature of induration. 
Examples. 

538 Softening. Specific causes. Common causes. Nature. Examples. 

539 Treatment of induration and softening, opposite, but parallel. 

540, 541 Treatment of softening generally tonic and supporting. Specific 



Section V. — Transformation of Textures - - p. 299 — 302 

542 Transformation generally degeneration. Exceptions: skin, and mu- 

543 cous membrane. Transformation of muscle. Fatty transforma- 

544 tions. Fatty degeneration of the liver; of tubercle. Osseous trans- 
formation. 

545 Treatment of transformations. 

Section VI. — Deposits in or upon Textures - p. 302 — 321 

546 Definition of deposits. Nature. Division. 

547 Euplastic deposits. Cicatrices. Reparation effected by three modes. 

548 Dr. Macartney's view of the modelling process. Treatment. Union 

549 by first intention: adhesive inflammation. Dr. Carpenter's account 
550, 551 of organization of cicatrices. Reparation by blood. Remedial 

552 measures to promote the euplastic process. 

553 Cacoplastic and aplastic deposits. Examples of the former: structure; 

554 causes, general and local. Cirrhosis. Granular degeneration. 



CONTENTS. XV11 

Paragraphs 

555 Semi-transparent gray and tough tubercle. A degraded kind of 

556 lymph. Connection with other cacoplastic deposits. Tendency of 

557 cacoplastic deposits to contraction; effects; intimate nature. To de- 
generation into aplastic: this common tendency of tubercle. Form 

558 of tubercle: causes. Opaque change indicates aplastic degradation: 

559 causes of this change. Primary aplastic deposits; proof of degraded 
nutrition. Yellow tubercle. Maturation and softening: the converse 

560 of contraction. Chemical nature. Fat in tubercle. Changes of 

561 tubercle from adjoining textures. Quiescence of tubercle: sponta- 
neous changes; induration: plastery and petrifactive change. 

562 Causes of cacoplastic and aplastic deposits: congestion: chronic 

563 and asthenic inflammation: degraded plasma of the blood, with de- 
fect of red particles. Symptoms. Seat of tubercles. Reason of 

564 liability of the lungs considered. External or exciting causes of 
tubercles: operation explained. 

565 Treatment of cacoplastic and aplastic deposits. Elements to be con- 

sidered. 
1. Disordered distribution of .the blood and its causes. Remedial 
measures. 

566 2. Disordered condition of the blood, and its causes. Remedial and 

preventive measures. 

567 3. Deposits already present; their effects and changes. Medicine of 

little efficacy. Mercury; alkalies; iodides; sarza; naphtha; tonics. 

568 External counter-irritation. Treatment during degeneration and 
softening of tubercle. Nitric and hydrochloric acid. Diet, &c. 

Morbid Growths - - - -- - - - p. 321 

569 Definition. Names and divisions. Analogous and heterologous, &c. 
Section VII. — Non-malignant Growths - - p. 322 — 328 

570, 571 Definition. Serous cysts distinguished from enlarged natural sacs. 

572 Encysted Tumours. Hygroma. Steatoma. Atheroma, &c. Dr. 

573 Hodgkin's view of the cystiform origin of tumours. Sarcomatous 
tumours. Vascular sarcoma. Adipose sarcoma. Polypus. Neu- 
roma. Choudroma. Osteo-sarcoma. 

574 Pathological cause of morbid growths. Parasitic! 

575 Hydatids.- Proofs of separate vitality; nature and origin; situations; 
576, 577 death. Echinococcus. Cysticercus. Distoma. 

578 Medical treatment of morbid growths, and their effects. 

Section VIII. — Malignant Growths - - - p. 329 — 338 

579 Definition. Character of malignancy; varies in degree. 

580 Carcinoma the generic term. Varieties traced to different degrees of 

activity of cancerous matter. Some chronic, some acute. Ele- 

581 mentary structure of cancer: cells; forming fibres, &c. Disposition 

582 to grow at expense of nutrition: parasitic nature] germs or ova: 
communicated by injection into veins. Local origin of cancer as 

583 modification of nutrition. Dr. Hodgkin's view. Practical deduc 
tionsfrom pathology of cancer. Mode of origin. Varieties of can- 
cer explained by difference in quantity and activity of germs, and 
activity of nutrition in adjoining textures. Scirrhus is the chronic 
I'm, ii. Symptoms: tendencies: open cancer: growth: destructive 

mi part, and on whole frame. Pancreatic, mammary, lurda- 

584 ceous, anil solanoid intermediate forms of cancer: mode of growth. 

585 Encephaloid cancer the acute variety: in parts and subjects where 

586 nutrition active. Cause of rapid growth of encephaloid disease. 
Colloid cancer, the cancerous element in a separate fqrm. Other 
varieties from form, &c. 



XVlll CONTENTS. 

Paragraphs 

587 Melanosis. Varieties. Peculiar black matter: its nature. 

588 Treatment of malignant growths. Indications. 1. To extirpate them. 
589, 590 2. To retard their development. 3. To counteract their effects. 

Means of attempting the fulfilment of these. 
Section IX. — Disorders of Mechanism p. 338, 339 

591 Changes in mechanism, elements of disease. Examples. Dilatation. 

592—594 Contraction. Rupture and laceration. Displacement and com- 
595 pression. Contortion. 



CHAPTER Y.— CLASSIFICATION, SYMPTOMS, AND DISTINCTION 
OF DISEASES. 

Section I. — Nosology p. 340 343 

596,597 Definition of special diseases. Methods of classification. Symp- 

598,599 tomatic. Methods of Sauvage, Cullen. Method of I'm. I. Modes 

600 of pathological classification. Definitions of disease with refer- 

ence to pathology. 

Section- II.— Skmeiolory and Diagnosis - - - 343—355 

601,602 Definition of symptoms and signs. Physical signs. Examples. 

Those of disease known by comparison with healthy standards. 

603 Modes of learning healthy standards. Standard of symmetry. 

604, 605 Anatomical standard. Physical signs explained by physical law's. 

606 Vital symptoms, called also functional and physiological, general 

607 and rational. Examples. Sources of symptoms. Pulse. Skin. 

608 To in'. Stools. Urine. Knowledge of pathology best key to 

609 symptoms. Statistics a temporary substitute. Respective . 

610 physical signs and vital symptoms. Division and nomenclature 
of symptoms. 

611, 612 Diagnosis defined. Dow founded. Division into general and special. 
613 iosis, illustrated by problems, and modes of solution. Need 

61 * . of every branch of medicine in diagnosis. The tesl of ability 

615 and knowledge. Methods of examination with regard to diagnosis, 

aosis, and practice. 



CHAPTER VI.— PROGNOSIS: FOREKNOWLEDGE OF RESULTS OF 
DISEASE p . 356-376 

616 Definition. Prognosis, empirical or rational Empirical that of in- 

fant medicine. Prognostics of Hippocrates. Good and bad 

617, 618 /fo/wwMr/prognosis described and exemplified. Circumstances from 

619 which prognosis may be formed. Cause of the disease. Of the 
subject: age; sex; temperament; previous 

620 previous habits; condition at the time of attack. Of tht ■ 

621 situation and nature; extent and progress. Of the symptoms.- 

622 character. Good symptoms. Bad symptoms.- signs of impediment 
to a vital function, and approach to one of the modes of death. 

623, 624 Operation of all modes of death on the' blood proved. Modes of 

■ death arranged in table. 

625 Death by syncope.- by spasm of the heart; causes; by loss of irrita- 

bility; causes; poisons; diseases. Symptoms of approach. 

626 Death by asthenia.- from diseases. Symptoms of approach. 

627 Death by asphyxia. Distinction. Symptoms. Causes. Varieties. 

628 Death by coma. Causes. Symptoms. ' Combined with excitement 



CONTENTS. 



Paragraphs 



of medulla. How does coma cause death] Medullary symptoms 

the most serious. 

629 Death by paralysis. Injuries to the medulla-, to the afferent nerves 

630, 631 of respiration; to the efferent nerves. Examples. Paralysis of 

632 spinal nerves with and without injury to the cord. With injury 
of cord itself, symptoms and fatal tendencies. 

633 Death by necrsemia. Explanation. Proofs of death of the blood. 

Mode of spreading death to other parts. External causes of ne- 

634 crsemia. Vital resistance to its causes. Symptoms. Modes of 

635 elimination of causes of necraemia. Intrinsic causes of necrsemia. 
636 — 638 Symptoms of death by necrsemia. Slow deaths, equal. 



CHAPTER VII.— PROPHYLAXIS AND HYGIENICS - - p. 377, 383 

639 Definitions. Prophylaxis connected with special pathology. 

640 Hygienics refers to means to resist disease generally, and to means 

which maintain the general health. 
{Dr. Clymer.) 

641 [Object of hygiene. Its importance. 

642 Effects of inattention to hygienics. On infants. 

643 Mortality among children in the English work-houses. 

644 Diminution in the mortality of children in London in the present 

century. 

645 Duration of human life in the adult. Average duration of life amongst 

the Romans and English. Greater mortality amongst the poor than 
the rich. 

646 Some of the chief causes of disease. 

647 Annual number of deaths from preventible causes of typhus in Eng- 

land and Wales. Mortality amongst English women from con- 
sumption. Effects of want of ventilation in trades people. Ill effects 
of boarding schools. 

648 Pernicious influence of a dense population on the diseases of the re- 

spiratory apparatus. 

649 Insufficiency of food. Want of variety in the aliment. Sources of 

scurvy. Imperfect nutriment a probable cause of epidemic typhus 
and scarlet fever, &c. 

650 Necessity of exercise. Walking. Riding. A cheerful companion 

indispensable. 

651 Attention to the moral condition of the patient. Change of scene and 

occupation. Proper time for study. 

652 General hygienic rules for the sick. Dry and well ventilated apart- 

ments. Temperature of the sick room. Light. Fumigations. Risk 
of moving patients. 

653 Cleanliness indispensable. Mode of changing the linen of patients. 

Auxiliary means to receive the excretions and prevent pressure. 

654 Food. Amount of nourishment necessary. Rule for its administra- 

tion. Injudicious use of food. 

655 Removal of the excretions. 

656 Repose and quiet. 

657 Sleep. Manner of provoking it. 

658 The sensations. Emotions. Intellectual faculties. Conversation. 

Necessity of attention and sympathy to obtain the confidence of the 
patient. The fear of death. Propriety of communicating to patients 
their state. 

659 Hygiene of chronic diseases.] 



ON THE NEED OF THE STUDY OF 
GENERAL PATHOLOGY, 

AS THE FOUNDATION OF PRACTICAL MEDICINE. 



Extracted from an Introductory Lecture on the Principles and Practice 
of Medicine, delivered at University College, Oct. 1, 1842. 



[The following remarks may serve as an .introduction to the 
present work, as they were intended to be introductory to that 
part of the course of lectures which embraces the same topics. 
As an apology for the familiarity of their style, the reader may 
be reminded that they are printed as delivered.] 

State of practical medicine, as a study, and as an art — In- 
sufficiency of empirical and nosological medicine — Gene- 
ral pathology the true foundation for practical medicine 
— What is general pathology? — Its relations to clinical 
medicine — Noble nature and objects of medicine. 

******** 
I must further state another circumstance which greatly up- 
holds my anxiety to bestow my best exertions in teaching the 
subjects of my course. It is, the low position ivhich this most 
important part of medical science still holds with the public, 
and even with students. I feel this to be a matter of such mo- 
ment, that I propose to make the chief subject of this lecture, the 
state of practical medicine, as a study, and as an art. 

Compare the state of the practice of medicine with that of 
anatomy, phsyiology, and chemistry — the great fundamental or 
preparatory studies. How minute, how precise, how connected 
and definite are these! Yet how loose, indefinite, uncertain, 
unconnected, is the practice of our art. To the public it appears 
altogether vague — without any acknowledged principles. 

Is there any wonder, then, that quackery should triumph? 
2 



14 INTRODUCTORY LECTURE. 

that the public show their want of faith in legitimate medicine 
by their ready belief in any novelty that is not legitimate? Thus, 
one year, -St. John Long's plan; another year, homoeopathy; 
another, Morison's pills; another, the water-cure — rules the 
fashion. The public may show their ignorance by such credulity; 
but they show also the want of something plain and trustworthy 
in regular medicine. The public will not believe that the secret 
of the art is with a faculty which professes to follow experience 
only. The quack also can appeal to his experience; and that, 
too, in a way more striking and convincing than those who 
express doubts and admit difficulties. Thus, one who cures 
nervous diseases can calculate his success by the numerical 
method. In eight thousand cases he can count only twenty 
failures. Another tells you of an extraordinary per centage of 
success in cases of deafness, in which the 7nosl eminent prac- 
titioners had failed, &c. Hence you will find the partisans of 
quackery far more zealous in the defence of their favourite no- 
tions than others are in support of the regular art. No wonder 
that homoeopathy and the water-cure have their royal and noble 
advocates. Then there is a captivating simplicity in the theories 
of quacks. A certain high official personage pins his faith to an 
empiric who was form dener, and whose notion is, that 

all diseases proceed from buttercups. This is the theory: every 
man, woman, and child, cats mutton, beef, or butter, or drinks 
milk: every cow and sheep eats buttercups with its grass; butter- 
cups are rank and acrid weeds; ergo, all diseases proceed from 
buttercups. How. beautifully simple! How attractive, too, are 

■ iiiprehensive views ist and the water-cu 

They both agree in their pathology; all diseases arise from bad 
matter in the blood; they only differ in their mode of expelling 
it from the system. One purges out the peccant humour; the 
other washes and sweats it forth. There is something, too, very 
fascinating in the notions of homoeopathy: similia similibus me- 
dentur. Who cannot fail to admire the expansive genius of 
Hahnemann, who discovered that the best cure for a disease is 
the influence which caused it? 

On the other hand, the regular practitioner has nothing so 
plausible or so captivating to bring forward in explanation of his 
method. He has either no theory at all. and grounds his practice 
on experience, (in which we have said he is matched by the em- 
piric,) or, if he gives a theory, it is viewed only as aii opinion 
no better than the hypothesis of the quack, in an art so little 
founded on principles as medicine. So little favour does medi- 
cine receive from the public in its pretensions to science! 

How is it with the student? Surely to the student the prac- 
tice of physic must be as interesting as it is important — the 



ON THE NEED OF PRINCIPLES IN MEDICINE. 15 

useful application of all his knowledge — the winding-up of the 
drama of his studies — the rehearsal of the great performance of 
his life. Surely this must he a very attractive study? Quite 
the contrary." I believe it has been generally considered by 
students as the heaviest, most repulsive, most tedious of all sub- 
jects, (with, perhaps, a single exception.) Without the constant 
appeal to the senses with which awitomy attracts and rivets 
attention; without the beautiful connections and adaptation of 
means to ends which make physiology interesting; without the 
simplicity and striking phenomena which give a charm to che- 
mistry — the practice of medicine, as taught, is an enormous mass 
of dry detail; its science, mere glimpses into an unknown land; 
its rules, irregular tracks through a wilderness of confusion. 
Practical medicine is studied only from a conviction that it is use- 
ful and necessary; and not because it is easy or agreeable. 

Further, there are a great many students, certainly not the most 
industrious, who shirk the disagreeable duty, pleading that it is 
neither useful nor necessary; and that the practice of medicine is 
only to be learnt at the bedside with whatever aid books can sup- 
ply. It would speak more in favour of this opinion, if its advocates 
acted up to their dogma, and proved, by their constant and dili- 
gent attendance in the wards of the hospital, that they seek there 
the knowledge which they profess to be unable to obtain in the 
lecture-room. But, so far as my observation has gone, I do not 
find this to be the case. It is not those that neglect the lectures, 
but those who most regularly attend them, that prove to be atten- 
tive students in the hospital. 

But, although useful and necessary, it cannot be denied that the 
study of the practice of medicine, both by books and by lectures, 
is at first very difficult and irksome — more so than other studies. 
But why is it so? This is a serious matter. Let us examine a 
little into it. Is the fault in the imperfect state of the subject, or 
in the method by which it is taught? The science of practical 
medicine is undoubtedly very imperfect; but I think it can be 
shown that there is a still greater imperfection in the method by 
which it is taught. 

As anatomy and physiology, with chemistry, are the studies 
preparatory to medicine, one might expect that they should be 
madei fundamental to that of medicine; that, starting from the 
knowledge of the healthy body, as taught by them, the transition 
should bo easy and intelligible to disease — first, in its lowest de- 
grees and simplest form; then to that which is more compound, pro- 
nounced, and more removed from, but still comparable with, the 
healthy standard, instead of this, lecturers and writers plunge at 
once into the mazy thickets of inflammation and fever — subjects 
so complicated, so changed from any thing taught by previous 



16 INTRODUCTORY LECTURE. 

study, that anatomy and physiology afford little help: and no 
wonder that the student (like many observers and reasoned on the 
same topics) becomes confused and bewildered in the complexity 
of the subject; or, if he do make out any thing, it is something 
isolated, abstract, about fever or inflammation itself, without its 
natural relations to health and to other diseases. 

This plan of proceeding may be compared to a person begin- 
ning the study of mechanics with the steam-engine; or to the 
student of chemistry commencing with organic matter. 

The general result is, that where any distinct notion of disease 
is acquired, it is one not at all founded on previous physiological 
knowledge, but it is a new idea of disease as an absolute separate 
thing — not a mere condition consisting of altered function and 
structure, but a being, the character and history of which are to 
be detailed like that of a plant or an animal. And when special 
diseases are treated of, the same individualizing process is pur- 
sued through all the jargon of the schools. Each has its nosology, 
classification, and definition; its predisposing, exciting, and proxi- 
mate causes; its theory, rat iosymptomalum; its diagnosis, prog- 
nosis, indications of cure, fulfilment of these, juvantia et Iseden- 
tia, and prophylaxis! 

With all this formidable array to each disease, the practice of 
physic was an arduous study in the days of Cullen. What must 
it be now, when the diseases of Cullen's nosology have been al- 
most doubled, and the facts relating to them have been more than 
doubled? 

lint let us follow the student, well crammed with his nosolo- 
gical list, their definitions, &c., to the bedside. Let us see how 
his knowledge, so meritoriously and laboriously obtained, will 
serve him in the hour of need. In a few cases of fully developed 
and well marked acute diseases, such as pleurisy, scarlet-fever, or 
rheumatism, he may get on pretty well; but in the commoner 
description of cases, acute or chronic, in their early stages, in their 
endless variations from peculiarities of constitution or from com- 
plicating causes, he find himself continually puzzled: the phe- 
nomena do not correspond with any of Ins defined diseases; they 
frecmently change their character in a way that he cannot ac- 
count for; his prognosis is falsified; his diagnosis fails; and his 
treatment, although not always unsuccessful, does not answer 
according to his expectations; some patients recovering whom he 
expected to die; others dying, . or not impro ving, whom he ex- 
pected to recover. 

Disappointed in the failure of his nosological learning, the 
young practitioner more and more mistrusts it, and falls into a 
routine of empirical practice. Without troubling his head about 
the name or nature of diseases, he thinks solely of their treat- 



ON THE NEED OP PRINCIPLES IN MEDICINE. 17 

ment; and, begrudging the time that he has spent with books 
and lectures, he decries every thing that is not practical. 

Still he is obliged to retain some notions of the theory of dis- 
ease; but they are general notions, and not fettered by definitions. 
He still studies symptoms: he seeks in the pulse and heat of 
skin indications of fever and inflammation; he looks to the 
tongue and alvine evacuations for proofs of disorder of the 
digestive organs; he judges by the complexion and muscular 
strength the state of the constitution. Instead of troublesome 
scholastic definitions, he uses convenient, general terms, which 
may be taken in a pretty vague sense — such as irritation, con- 
gestion, constitutional weakness, cachexia, disordered digestive 
organs, scrofula, scorbutic habit, and the like; and his remedial 
measures are designated in the same convenient general terms — 
such as soothing, cooling, supporting, stimulating, alterative, puri- 
fying, &c. ■;. _ 

In short, he has, in practice, learned himself, in a loose way, at 
the expense of previous studies, and sometimes, it is to be feared, 
at the expense of some bad practice, Avhat he ought to have been 
properly taught as the foundation of his studies — general patho- 
logy. Thus we are led to the presumption that general patho- 
logy is the proper basis for practical medicine; and I venture to 
affirm, that a chief reason why the practice of medicine has been 
commonly so distasteful, and so difficult in its study, and so unsa- 
tisfactory when tested at the bedside, is, because its foundation, 
general pathology, has not been efficiently taught. 

We have just met with a practical illustration of the truth, that 
general pathology is a more efficient help at the bedside than such 
knowledge of diseases as is to be obtained only from nosological 
definitions and details. Before I proceed to exemplify this truth, 
by matters of every-day experience, let me first briefly point out 
why it is so. 

Without the connecting link of general pathology, practical 
medicine derives little or no aid from anatomy and physiology. 
Instead of being founded on them, it is studied and practised quite 
independent of a full knowledge of them, and is generally acquired 
in proportion as they are forgotten. This kind of practical medi- 
cine is much the same as that of old women and nurses; it con- 
sists chiefly of treating symptoms, or groups of symptoms, (called 
diseases,) by remedies that have been found useful in similar cases, 
without the trouble of inquiring about the causes of the symptoms, 
or the precise seat of the disease. Thus, if a person complains 
of headache and giddiness, leeches are applied, and purgatives 
are given, because they have been found useful in similar cases. 
An intimate knowledge of the structure and functions of the con- 
tents of the head would give no further help in the use of these 

2* 



IS INTRODUCTORY LECTURE. 

remedies; nor suggest others, if these be found to fail. If they do 
fail, the only resource is in experiment: first one thing is tried, 
then another, until much mischief may be done, or at last, per- 
chance, the right remedy may be hit upon; and this may be the 
very opposite of those first used. Long experience may make 
the symptom-treating practitioner more successful, if he be an 
observing man; because it will acquaint him with additional 
symptoms to be considered for the guidance of the treatment. But 
there are few of this class of practitioners who are carefully ob- 
serving men, who do remember and profit by their experience: 
they more generally, like their sisters, the nurses, keep pretty 
close to their first notions; and although age and the name of ex- 
perience may screen their failures, alas for the young adventurer 
who sets sail on this tack! 

But the benefit of such experience is gained at the commence- 
ment by the student of pathology. He has learnt to trace symp- 
toms to their causes. Having been taught, by anatomy, the 
peculiarities of the circulation in the head — and by physiology, 
confirmed by clinical observation, that this circulation may be 
similarly impeded by opposite causes, inanition as well as fulness, 
— he is prepared to find out, through other symptoms, which is 
the cause of the headache in the case before him; and he adapts 
his remedies accordingly. 

In fact, a true pathology, or sound principles of medicine, is 
the embodiment of the result of experience in disease, with a 
knowledge of structure and function in health. It is the only 
connecting link between the preparatory sciences and practical 
medicine. Without it, these are disjecta membra; luith it, they 
form a connected body of science — young yet, it is true, and fall- 
ing short of the objects of the art, but already available for 
much, and needing only the growth and continued support of its 
chief members, especially anatomy, physiology, and clinical ob- 
servation, to become the perfect and efficient director of practical 
medicine. 

The great proof of the practical utility of general pathology is, 
the aid which it gives in the study of clinical medicine, and the light 
which clinical medicine continually throws on it. The states which 
the practitioner has to treat are often too indefinite or too mixed 
to correspond with any of the definitions of special disease. They 
frequently consist of functional disorder, varying with time and 
circumstance, or changing its place, so as to present no fixed 
characters. But, compared by the pathologist with the standard 
of health, and analyzed from their complexity, their nature be- 
comes intelligible, and their proper treatment obvious, so far as 
means are possessed to counteract or control that which is wrong. 
Let us take one out of many examples. The disordered state of 



ON THE NEED OF PRINCIPLES IN MEDICINE. 19 

health, for treating which Mr. Abernethy gained such a repu- 
tation, is one of the commonest ailments we have to prescribe 
for: some call it, with Abernethy, "all stomach," others, "liver;" 
others, "disordered constitution;" others, "indigestion;" but how- 
ever differently they may name it, few refuse to treat it, as 
Abernethy did, by regulated diet, blue pill, and mild saline 
aperients, repeatedly administered. Now, the pathologist ana- 
lyzes the symptoms of such a state, and hi the white or yellowish 
furred tongue, morbid eructations, tender epigastrium, sometimes 
full right hypochondrium, with extended dukiess on percussion, 
the discoloured fseces, the high-coloured and turbid urine, he 
finds proof of congestion and disturbed secretion of the liver and 
upper part of the alimentary canal; and he recognises hi the 
remedies employed, means which, by increasing the secretions, 
relieve the congestion; and if these fail, he can suggest other 
measures which he knows to be efficacious in removing con- 
gestion, and restoring the natural secretions. Again, what con- 
fusion in diagnosis, as well as in practice, has arisen, from com- 
prehending, under the specific name hysteria, the most opposite 
and most varying conditions, merely because they are consorted 
with some nervous phenomena; so that this word becomes 
almost synonymous with female diseases. But, pathologically 
considered, the confusion in diagnosis, and, in some measure, the 
perplexity in regard to treatment, cease. In one group of such 
cases, the pathologist finds really such signs of disordered uterine 
function as would justify the name; other symptoms, however 
varied, taking their origin from this disorder; and he thus dis- 
covers the necessity of directing the treatment to this cause. In 
another group, again, he finds the uterine function impaired; but 
this only in common with other functions: and all this hi conse- 
quence of a want of blood throughout the body, which want is 
denoted by the waxy complexion, the pallid lips and gums, the 
loose yet easily quickened pulse, the panting breath, the feeble 
limbs, &c. Here the restoration of the blood is the obvious indi- 
cation; and in proportion as this is effected, the symptoms of 
nervousness, debility, and loss of function, disappear. In a third 
group of cases, called hysterical, the pathologist discovers the op- 
posite condition, that of sanguineous plethora, which, inde- 
pendently of any disorder of the uterus, causes trouble, sometimes 
in one part, sometimes in another, but especially in the nervous 
system, which, in most females, is peculiarly liable to disorder. 
Here, too, he is led to the most appropriate treatment. 

This is but one instance out of many that might be adduced 
to show the great practical utility of a good knowledge of patho- 
logy. In fact, the leading rules of practice, those which guide 
the most experienced men, (although many are not aware of it, 



20 INTRODUCTORY LECTURE. 

and would not acknowledge it,) are founded on general views of 
diseased function and structure — that is, general pathology. 
You will not find that practical men treat a disease merely 
according to its name, or according to the nature of the local 
mischief. Inflammation is not always to be combated by blood- 
letting, nor haemorrhage by styptics. The condition of the system 
— that is, of the functions, is to be taken into account; and the 
variations of this condition, the states of sthenia and asthenia, tone 
and debility, excitement and depression, plethora and anaemia, are 
the very subjects which general pathology explains and shows 
how to treat. 

I say, practitioners do act more on general ideas of disease than 
on their knowledge of particular diseases. They feel the pulse 
and the skin, to guide them in the use of blood-letting, whether 
they have found out the special disease or not. They examine 
the tongue, and inquire as to the state of the evacuations, to 
guide them in the use of purgatives, under whatever complaint 
the patient labours. They consider the complexion and bodily 
strength in connection with dietetic measmcs; and the chief treat- 
ment of convalescence depends on rules suggested by general 
pathological knowledge. 

There are other very important departments of medicine which 
are comprehended in general pathology, and with it have been 
too much neglected — I mean, the study of the causes of disease 
and their modes of operating on the living body, {etiology,) and 
the means by which they may be avoided or counteracted, in- 
cluding prophylaxis, or the prevention of disease; and hygienics, 
preservation of health. Neither of these subjects can be satis- 
factorily comprehended without a sufficient knowledge of the 
elements and laws of disease. 

Is it not, therefore, most important that these general views, 
which are so practical and so extensive in their application, 
should be well founded and carefully studied? Is it right that the 
leading doctrines of disease, — leading not in theory but in practice, 
— should, as hitherto, be left to be picked up irregularly, from 
casual retrospects of study or experience, when they may be 
learned as the very groundwork of practical knowledge? 

What, then, is this general pathology, which we extol so 
much as the proper foundation of practical medicine? Let us first 
state what it is not. It is not a collection of hypotheses hung on 
solitary facts, and ingeniously devised to explain this or that 
symptom, or the modus operandi of tliis or that remedy. It is 
not any thing floating on (I cannot say, founded on) conjectural 
notions in anatomy and physiology, such as the existence and 
circulation of a nervous fluid, the presiding influence of the 
ganglionic system, or the vital attractions and repulsions of the 



ON THE NEED OF PRINCIPLES IN MEDICINE. 21 

circulating fluids: notions which, however they may hereafter be 
substantiated, are at present too speculative to form a foundation 
for pathology. Nor is it a partial set of opinions, erected on one 
only of the many pediments of fact, on which the science of 
medicine should stand. Healthy anatomy, physiology, physics, 
chemistry, the study of clinical medicine, that of materia medica, 
morbid anatomy — neither of these alone can furnish a foundation 
for pathology — that foundation must be formed by ale — the facts 
which all supply constitute the material of which it is built, and 
the general facts or laws of all must be brought to bear on the 
arrangement of these materials in the construction of a system 
of pathology. 

Some advancement in these contributory departments is neces- 
sary before the work can be begun, and it is because they have 
advanced that the opportunity is afforded. Why should the 
science of medicine remain in a state of powerless infancy, when 
its members are progressively acquiring strength and maturity? 
Why should the art of medicine still be a groping about in 
blind empiricism, and an unintelligible confusion of facts, when 
science even now can afford it the beginnings of light and of 
order? 

I have just said that the contributory sciences are sufficiently 
advanced to be generally applicable to practical medicine. The 
proofs of this in detail will, I trust, appear in the progress of 
the course; but I will adduce here a few examples of a prominent 
kind. Disease, in so far as it is the result of mechanical change, 
or in part made up of mechanical elements, may be properly 
treated by mechanical means. It was the knowledge of this fact 
which led Dr. Arnott to invent that admirable contrivance, the 
water-bed, by which disease is often prevented and removed; 
and he has lately made another application of physical science, 
in modes of applying pressure to parts with such equality as to 
control to any degree the circulation of the blood through them, 
and thus to relieve pain, remove congestion, subdue inflamma- 
tion, heal ulcers, disperse swellings, and arrest the growth, if 
not to effect the removal, of tumours and other morbid produc- 
tions. Disease, so far as it is physical in its nature and in its 
effects, is to be investigated by physical means. Hence the 
advantage of acoustic science in assisting us in diagnosis of 
internal disease, and of optical science in enabling us to wit- 
ness the minutiae of its operations and its products. I need 
scarcely add, that the treatment of disease is in some instances 
founded on, and in most cases guided by, knowledge thus 
obtained. 

As an example of improvements in anatomy and physiology 
bearing on practical medicine, 1 may mention the late researches 



22 



INTRODUCTORY LECTURE. 



on the nervous system, and especially those of Dr. Hall. By 
these, much that before was unintelligible in diseases of the ner- 
vous system has been satisfactorily explained, and their diagnosis 
and treatment have received proportionate aid. Considerable 
light has been thrown on diseases of the liver and of the heart, 
by recent anatomical and physiological investigations of these 
organs. 

The aids afforded by chemistry to the materia medica have 
been long acknowledged, and continue to increase: but chemistry 
is growing in importance in its applications to every department 
ot practical medicine. It is now directly useful in the diagnosis 
and treatment of diseases of the urinary organs. It furnishes a 
key to the most important rules of diet,' in health as well as in 
disease, and bids fair lo supply much that is wanting in explana- 
tion ol the origin of many maladies, and the most direct mode 
of preventing them. It is through the aid of organic chemistry, 
now tar advanced— advanced, too, mainly by the labours and 
genius of an illustrious chemist, who this "day honours us with 
his presence, (Professor Liebig)— that we may hope that experi- 
mental physiologists and clinical observers will be enabled to solve 
some of the dark problems of the operation of medicines; a sub- 
ject replete with practical importance, yet one that still lies chiefly 
m the region of conjecture. 

It will not be disputed that clinical observation's lately done 
much for the advancement of the science of medicine; and this 
not only because it is the test by which the contributions of other 
branches are tried, hut also because in itself it is carried on with 
the minuteness and precision which are essential to science. 
This precision must apply, not only to the modes of calcul 
facts, but also and most particularly to the correct determina- 
tion and classification of these facts. The accuracy of counting 
is a mere facility in common arithmetic. The accuracy of ob- 
serving and arranging the tacts to be counted is the higher and 
rarer quality. Both are required hi the prosecution of clinical 
research. 

The whole department of practical medicine teems with ex- 
amples of the benefits which it has derived from morbid anatomy. 
What should we know of the nature, products, and tendencies of 
inflammations, and other diseases Avhich alter the structure, but 
for the scalpel revealing them to our very sight and touch? The 
mmuteness with which it (morbid anatomy) has been pursued in 
connection with clinical observation, in regard to diseases of the 
lungs, heart, liver, kidneys, and alimentary canal, deserves espe- 
cially to be mentioned as the great source of our unproved theory 
and practice in these complaints. 

It is not a general or superficial knowledge of any of these 



ON THE NEED OF PRINCIPLES IN MEDICINE. 23 

fundamental sciences that will avail to make them profitable to 
medicine. It is where their facts and laws have been carefully 
studied, in relation to the living body, that the .advantage has 
become practical; and this study has in many instances deve- 
loped new phenomena, which reflect light also on the contri- 
butory science. The application of hearing to the distinction 
of diseases has given rise to a more intimate knowledge of 
acoustic science. Some of the most interesting facts and laws 
of organic chemistry have resulted from researches instituted 
with reference to the investigation of disease; as, for example, 
those of Prout, Wohler, and Liebig. In regard to anatomy and 
physiology, the instances are abundant. For example, the re- 
searches, of Charles Bell, Foville, and M. Hall, on the nervous 
system, and those of Astley Cooper on the testicle and mamma, 
were conducted with express reference to diseases of these organs, 
and were often suggested by the knowledge previously possessed 
of these diseases. In this respect they followed John Hunter, 
who throughout his anatomical labours had an eye to pathology, 
and by observing disease was continually guided to objects for 
these labours. 

So we shall find, as we proceed to the details of pathology, 
that subjects which require further research are continually pre- 
sented to us in a practicable form; and I shall take occasion to 
point out some of these, in the hope that some among you may 
be induced to cultivate ground which is rich in promise of im- 
portant practical results. 

Do not suppose, because I insist strongly on general patho- 
logy being the proper basis of practical medicine, that this will 
lead us to neglect the superstructure, special pathology. Indi- 
vidual diseases will be the chief subjects of the course, occupying 
100 out of 130 lectures; and I trust that their details will become 
much more comprehensible by the arrangement into which gene- 
ral pathology will enable us to distribute them. It is because I 
fee] I he vast importance and extent of our knowledge of indi- 
vidual disease, that I would endeavour to introduce you to it from 
the most advantageous and commanding position; and that posi- 
tion is afforded by a previous acquaintance with the general fea- 
tures of disease. In fact, individual diseases are like the leaves 
and boughs of the tree, of which general pathology constitutes 
the trunk and great branches — all preserving an identity and 
connection, yet each portion having peculiarities of character 
which require separate study. Or medicine maybe compared to 
a greal edifice, the foundation and great entrances of which re- 
presenl pathology, "which generally give the proper approach to 
the separate rooms, special diseases. To some of these, in the 
imperfeel state of the structure, there may be access only by the 



24 INTRODUCTORY LECTURE. 

dark back ways of blind experience, which there must not be 
neglected; but this is no reason for making these dark back ways 
the only entrance. 

Throughout our examination of the details of disease, we shall 
find the principles of general pathology continually exemplified; 
and through these principles the mind can master the details to 
an extent wholly unattainable by those who pursue them as un- 
connected matters of fact. Those who begin the study of prac- 
tical medicine by attempting to learn the details of diseases, are 
like those who would endeavour to master all the facts of chemis- 
try without any knowledge of the general facts or laws of chemi- 
cal action, affinity, and definite proportions; yet even in practical 
chemistry, or chemistry applied to the arts and manufactures, the 
most extensive and important services have been obtained from 
these very principles, applied to the details. 

But in treating of individual diseases, although we shall find 
our previous pathological principles of great use in explaining 
and simplifying the details, we are not to be tied to them when- 
soever experience varies from those principles, or goes beyond 
them; there, experience must be carefully followed. There is no 
subject in which this simple statement of fact is more frequently 
necessary than in regard to the modus operandi of medicines. 
It is quite true, that many curious speculations have been offered 
on this subject. In fact, it seems to be quite the hobby, or the 
Pegasus, of a very speculative class of men who call themselves 
practical. These can tell you to a nicety how mercury ernes 
syphilis; how opium causes sleep; on what precise parts of the in- 
testinal tube each variety of purgative acts, &c. But, as in most 
of such hypotheseSj there is much more of fancy than of fact; and 
as the fancy, if erroneous, may be mischievous in a strictly prac- 
tical matter, I shall be excused if I prefer giving you the naked 
matters of fact. 

The purpose of lectures on the practice of medicine is not 
merely to convey knowledge of disease and its treatment, but also 
to direct the mind in the ways of using this knowledge, and of 
acquiring more. Books will supply details which cannot be given 
in the lectures; but the more important additional source of infor- 
mation is clinical instruction. This is an essential part of the 
teaching of practical medicine. It is its demonstrative part, and is 
essential, not only because, like other witnessed phenomena, it 
appeals to the senses, but also because it is necessary to practise 
those senses in the examination of the signs of disease, and to exer- 
cise the reasoning powers in the interpretation of those signs, and 
in the further application of previously acquired knoAvledge. As 
general pathology is the connecting link between the preparatory 
studies and practical medicine, so clinical instruction is the step 



ON THE NEED OF PRINCIPLES IN MEDICINE. 25 

between the knowledge of medicine and the personal application 
of that knowledge in actual practice. I need not say that each 
of these is. most necessary to the formation of a good practi- 
tioner: but there are especial reasons why clinical study, con- 
nected with the practice of medicine, is more indispensable now 
than it ever was. In former days, medicine was little more than 
a matter of routine; and the examination of a patient was summed 
up in feeling the pulse, looking at the tongue, and asking a few 
questions as to the feelings and functions, and this was 'often 
done for the sake more of form -than of information; for the pills 
and draughts were much the same in most cases. This was little 
better than quackery, and required no great preparatory study. ■ 
That it sometimes succeeded to win the favour of the public is 
not surprising, seeing that quackery often had a similar or greater 
success. Then the ignorant practitioner could disguise his empti- 
ness by a cloak of mystery, and a solemnity of manner, and could 
command confidence by dropping a hint ' about his experience, 
tact, and intuitive perception of disease. But, ignorant as people 
still are in medical matters, they are not so dull as to be deceived 
by these means. They have a smattering of physiology and the 
use of remedies, and they are become troublesomely inquisitive; 
and if they are taken in, it is by the clever quack, who is ready 
with his theories and persuasive proportion of cures, and not by 
the unsatisfactory regular, who examines but little, and cannot 
explain his views or his practice. In short, the public look for 
what they have a right to expect, thoroughly educated practi- 
tioners, who prove their qualifications by their careful method of 
investigating disease, the clearness with which they give their 
opinions, and the general correctness of those opinions. 

This, then, is another reason for thoroughly availing your- 
selves of practical instruction, especially in the clinical depart- 
ment. The great importance of this. department has occasioned 
the adoption of extended measures for teaching it. I trust that 
you will prove, by the assiduity and success of your practical 
studies, that the college has not adopted these means in vain; but 
that, as in the preparatory branches, so in the finishing of your 
)m« die; 1 1 education, you will obtain that high standard of qualifi- 
cation that must insure the confidence and esteem of those among 
whom you may exercise your calling. 

Gentlemen, we have great pleasure in meeting you again for 
the session — those who have favoured us before, as old friends; 
new-comers we welcome to the work, which, although arduous, 
is nol one of drudgery. I almost envy the pleasure, in young 
and ardenl minds, of rising step by step in knowledge, and de- 
lighting in the wonders and beauties of the enlarging view. I 
admil thai the ascent is arduous — that it requires hard labour, 

3 



26 INTRODUCTORY LECTURE. 

and no little self-denial. But is there no compensation in the de- 
light of acquiring knowledge and intellectual power? No gratifi- 
cation in learning and contemplating the intricate beauties of the 
most perfect part of the creation? Is there no moral and reli- 
gious good to our own minds in tracing out and unveiling its 
frailties, weakness, decay, and death? No satisfaction in learning 
of means which a gracious Providence supplies for preventing 
and removing the ills which flesh is heir to; for relief of pain, 
suffering, and weakness, and restoration of health and strength? 
And if from present studies you carry your anticipations onwards 
to their final object in practice — under heaven, yourselves to ease 
suffering humanity, and to invigorate and prolong life — is the 
pursuit less noble, or less worthy of your highest thought? Need 
I say more for the intellectual and moral greatness of our art? 

Is a study noble in proportion to the breadth, and depth, and 
diversity of the knowledge on which it is founded? Then, think 
of medicine; how she levies her contributions from every branch 
of knowledge. The human body exhibits a machinery so per- 
fect, that the most skilful mechanical philosopher may take les- 
sons from studying it. It contains a laboratory so diversified, 
and chemical processes so subtle, that therein the ability of the 
most expert chemist is far surpassed. But the knowledge of the 
student of medicine must go beyond that of the mechanical and 
chemical philosopher. He must study those vital properties.!)! 
which they can tell him nothing. He must become acquainted 
with the attributes of life operating in matter. In animal gene- 
ration, nutrition, growth, secretion, motion, and sensation; in the 
variations of these processes, in their decay, and in their cessa- 
tion, which is death, he has a complicated study, peculiarly his 
own, in addition to those of a more elementary nature. He has, 
besides, to contemplate the body under disease, and to bring to 
his aid the three kingdoms of nature, and almost every art and 
every science, for agents and means to counteract and control 
that which disturbs its well-being. But is the body the only 
object of his care? No. Mind and matter are too closely com- 
bined to be studied or treated apart. To medicine alone it be- 
longs to contemplate and to treat the entire max — physical, 
moral, axd ixtellectual. What can I say more of the intel- 
lectual greatness of our art? 

Neither shall I strain your thoughts far to remind you of its 
moral worth. See its effect on masses of mankind, displayed in 
the progress of the happy discovery of Jenner! See how even 
barbarous people and idolators, Mussulmen, Hindoos, and Chi- 
nese, respect our nation only for the medical aid which it can 
supply. So that it has happened that medicine has become the 
handmaid of religion — a bond between countries, a peace-maker 
between nations. 



ON THE NEED OF PRINCIPLES IN MEDICINE. .27 

But let us not vaunt ourselves. Listen to one who speaks of 
our art — and that one the eloquent ambassador from the United 
States, the Honourable Edward Everett. I quote from the Times 
of the day before yesterday: — " For what was that which consti- 
tuted the chief pride and glory of the British nation? They had 
heard of the intercepted letter from one Chinese chieftain to an- 
other; and what was the characteristic which had excited the 
admiration of the mandarin of a great and important empire, 
reeling at the time under' the blows of the British government? 
Was it the military prowess of their countrymen? Was it the 
steam-vessels of war reaching coasts in defiance of the deso- 
lating simoom? Was it their arms — their artillery— their skill of 
engineering, which civilized nations now brought to the strategy 
of war? Was it this, or any of these, which had struck with won- 
der, and awe, and admiration, the barbarians of China? No! It 
was the humanity of British physicians and surgeons — their 
management of hospitals, and the generous kindness which was 
extended to the sick and wounded, even of a hostile nation — 
which moved them with astonishment, and excited their sympathy 
and regard. These were some of the arts of peace which extorted 
the admiration of an enemy, and which other states would do 
well to imitate." 

But if you would see the moral influence of medicine depicted 
in its liveliest hues, I would ask you to contemplate a domestic 
scene — a family whose hearts are wrung with a dreadful anxiety 
for one vibrating between life and death. What a ministering 
angel does the physician seem! How they watch his every look! 
With what breathless earnestness do they hang on his words! and 
those words, how they wing themselves to the souls of the hear- 
ers foi sorrow or for joy! Yet such scenes are passing daily and 
hourly in every class of society — in the mansion and in the cottage: 
they open the hearts of all; for the moral influence of medicine is 
bound up willi the treasures of life and health, and with all those 
endearing ties that make these treasures doubly precious. Nay, 
how often, with the hopes, or fears, of a blessed or an awful 
eternity! 

Do not think me too enthusiastic, nor that I overrate the pro- 
fession you have chosen. Morally and intellectually I cannot 
overrate it: and now, at the commencement of a new epoch of 
your studies, when toil and exertion are required, I would cheer 
iiikI encourage you, by reminding and convincing you of the in- 
trinsic gratification which these studies may aflbrd, and of the 
nobleness of the objects for which they prepare you. 

li is the fashion to decry our profession — to call it a poor pro- 
fession, a degraded profession. If it be poor and degraded, is that 
the limit of the calling, or of those who practise it; or rather of 



.28 INTRODUCTORY LECTURE, ETC. 

those who should have governed and protected it? Is the art of 
healing in itself less noble, because its practitioners, unsupported 
by the arm of civil power, and too often unsustained by a con- 
sciousness of their own dignity, have not raised it to the place in 
society which it ought to hold? Poor it may be, but degraded it 
cannot, .shall not be, so long as its foundation is science, and its 
end the srood of mankind. 



PRINCIPLES OF MEDICINE. 



EXPLANATION OF THE SUBJECTS OF THE WORK. 



1. The Principles, Elements, or Institutes of Medicine 
comprise those leading and general facts and doctrines regarding 
disease and its treatment, Avhich are applicable, not to individual 
cases only, but to groups or classes of diseases. The same 
branch of medical knowledge is also designated by the term 
General Pathology and Therapeutics, to distinguish it 
from special pathology and therapeutics, or the theory and prac- 
tice of medicine in relation to individual diseases. 

2. The principles of medicine may be deduced in part from a 
knowledge of animal structure and function, anatomy and physi- 
ology, conjoined with an acquaintance with the agents which 
cause and remove disease; but chiefly they are derived from a 
generalization of facts observed in an extensive study of disease 

. and iis effects, in the living and in the dead body. But so 
far as they have been ascertained, they become more intelligible 
to the studenl if explained synthetically, by first describing the 
causes of disease, then their operation on the body, and lastly, 
the resulting changes in function or structure which constitute dis- 
ease in iis more elementary forms. 

3. Etiology, or a knowledge of the causes or disease, will 
introduce us to 'their effect — disease; the nature and constitution 
of which will then be considered under the head of pathogeny, 
or pathology proper. As this last subject is the chief one to 
be treated, ii will form the greater part of the work, and it will 
I)'' combined with such an elementary view of the principles of 
treatment as reason and experience may supply. 

4. A short general view will afterwards be given of the phe- 
nomena of disease, (semeiology,) the division and classification 
of disease, (nosology,) their distinction, (diagnosis,) their 
result, (prognosis,) and their prevention, (prophylaxis and 

HYGIENICS.) 

3* 



30 EXPLANATION OF THE 



DEFINITION OF DISEASE. 



5. The. reader is supposed to be acquainted with anatomy and 
physiology: without a knowledge of these, we cannot proceed 
even to a definition of disease. Disease is known only by com- 
paring it Avith the standard of health, which it is the object of 
anatomy and physiology to describe. 

6. Health consists in a natural and proper condition and pro- 
portion in the functions and structures of the several parts of 
which the body is composed. From physiology we learn that 
these functions and structures have to each other and to external 
agents certain relations, which are most conducive to their well- 
being and permanency, these constitute the condition of health. 
But the same knowledge also implies that function and structure 
may be in states not conducive to their permanency and well- 
being; states which disturb the due balance between the several 
properties or parts of the animal frame; and these states are those 
of disease. For example, physiology, as well as experience, 
teaches us, that in health the digestion of food is easy and with- 
out annoyance. But when, after food is taken, there is pain, 
sickness, eructation, flatulence, or the like, we know that the 
function of digestion is changed from the healthy standard — is 
diseased; and if this diseased function continues long in spite of 
remedies which usually correct it, and if on examining the abdo- 
men we find at or near the epigastrium a hard tumour, which 
anatomy teaches us is not there in health, we know that there is 
also diseased structure. 

7. We find, then, (§ 6,) that there ts disease of function, known 
by its deviation from a standard furnished by physiology ; and 
disease of structure, which we recognize by a standard supplied 
by anatomy, (§ 5.) These varieties of disease may be, and very 
commonly are, combined: there is seldom structural disease 
without some disorder of function; and in many instances 
functional disease is, or will be, accompanied by a change of 
structure. 

S. Looking, then, to anatomy and physiology as standards, 
we may define disease to be, a changed condition or proportion 
of function or structure, in one or more parts of the body. 

9. The standard of health is not, however, the same in all 
individuals: that which is health to one may be disease to 
another. Thus if we instance individual functions. The healthy 
pulse in adults averages from 70 to 80; yet there are some in 
whom 90 or 100 is a healthy pulse. Some persons fatten on 
a quantity of food on which others would starve. The animal 
functions, muscular strength and activity, nervous sensibility, 



SUBJECTS OF THE WORK. 31 

and the sensorial powers, vary still more in different individuals, 
yet all within the limits of health: but what is health in one 
would be decidedly morbid in another. Such unusual pro- 
portions of certain structures or functions constitute varieties of 
temperament; and although they can scarcely be called morbid, 
yet they certainly give, as we shall afterwards see, a proclivity 
to disease. 



CHAPTER I. 



ETIOLOGY.— ON THE CAUSES OF DISEASI 



SECTION I. 



NATURE AND DIVISION OF CAUSES. 

10. Disease sometimes originates within the body from a 
change in some of the componenl parts of the animal frame, 
without any obvious external influence: thus disorder may 
arise from an undue proportion or predominance of a function, 
as that of the nervous system; or of a constituent of the body, 
as in the case of sanguineous plethora. Such states, however, 
constitute -more commonly proclivity to disease than disease 
itself; and generally disease arises from causes extraneous to the 
body, although in many instances we may fail to detect these 
causes. 

11. A great variety <>f agents and circumstances may act on 
the body so as to produce disease; but in mosl instances there 
is not that uniform and constant relation between these as 
causes, and the diseases as effects, which we might expert from 
the analogy of causation in the simpler sciences. In chemistry 
or in mechanics effects certainly and uniformly follow causes; 
in physiology or pathology, no doubt, effects also ensue; but 
whether these effects shall be manifest as disease or not, will 
depend on many circumstances, of which we often cannot take 
cognizance. It is true that when the causes resemble and act 
like those of physics or chemistry, their proper effects will not 
fail to ensue. Thus, a cutting instrument, a red-hot iron, or 
a corrosive liquid, will not fail to produce disease, because it 
overcomes vital properties by physical and chemical, and disorder 
must follow. Further, certain poisons and other energetic agents, 
which act on without destroying the vital properties of living 
parts, may also, if of sufficient strength, pretty constantly produce 



PROXIMATE AND REMOTE CAUSES OP DISEASE. 33 

morbid effects. Thus, opium causes somnolency; tartar emetic 
excites nausea and vomiting, &c. 

12. But the common causes of disease are seldom of this de- 
cided and positive character; they are often present without dis- 
ease ensuing; and they are known to be causes only because 
disease is observed to ensue in a greater number of cases when 
they are present than when they are absent. Thus, improper 
food is a cause of indigestion, and exposure to cold is a cause of 
catarrh; yet many persons eat unwholesome food without suffer- 
ing from indigestion, and many are exposed to cold without 
"taking cold." But those who do suffer from indigestion ob- 
serve that they do so more after taking improper food; and those 
who are affected with catarrh can often trace it to exposure to 
cold. The reason of this uncertainty of action is chiefly in 
various powers by which the body resists the morbific influence; 
which powers vary much under different circumstances. The 
failure of this power constitutes a predisposition to disease. 

13. Causes of disease were formerly divided into remote and 
proximate: the remote include both the predisposing and the 
exciting causes, the only circumstances now considered as 
causes. They were called remote, not because they are distant 
or not in the body, but because they are not, like the proximate 
cause, a constant and present part of the disease. The term 
proximate cause was used by Cullen (after Gaubius) to repre- 
sent the pathological condition, or essential bodily change, on 
which the symptoms depended; and it was called a cause of the 
disease, because diseases were by him defined to be an assem- 

of symptoms. But this essential bodily change is rather a 
pari of the disease than a cause, and must be considered under 
the head of pathology. Discarding, then, the term proximate 

. we have only to consider the predisponent and exciting 
causes. 

14. The co-operation of both these kinds of causes is generally 
necessary to produce disease. A number of persons are exposed 
to cold: one gets a sore throat; another, a pleurisy; another, a 
diarrhoea; and a fourth escapes without any disease. All four 
were exposed to the same cause, yet it acted differently on all. 
The three first were predisposed to the. disease, which attacked 
them as soon as it was excited by the cold. The fourth had no 
predisposition; the exciting cause was therefore powerless; it 
was insufficient without the predisposing cause; as in the other 

the predisposition was insufficient until the exciting cause, 
the cold, was applied. 

15. Jn some cases, however, where sufficiently strong, what is 
in a smaller degree a predisposition, in a greater degree constitutes 

cause of disease, (§ LI:) thus a person with a very weak 



34 ETIOLOGY CAUSES OF DISEASE. 

stomach always has indigestion, whether an exciting cause be 
applied or not. So likewise exciting causes, if sufficiently strong, 
may produce disease without predisposition: thus a person not 
predisposed to indigestion may be pretty sure to cam it, if he take 
a sufficient quantity of raw cucumber, pickled salmon, or any 
such indigestible matter. Take another example. A healthy 
person living in a marshy district may not get an ague, until he 
becomes debilitated by any cause, such as cold, or fatigue: then 
the poison will act. But without his being thus weakened, if the 
exciting cause be made stronger by his sleeping on the very 
marshy ground itself, then the poison may act without predisposi- 
tion, and the ague begins, (§ 12.) 

16. The consideration of these facts throws some light on the 
nature of many prcdisponent causes. There is in organized 
beings a certain conservative power which opposes the operation 
of noxious agents, and labours to expel them when they are in- 
troduced. The existence of this power has long been'recognized, 
and in former days it was impersonated. It was the arclueus of 
Van Helmont; the anima of Stahl; the vis medicatrix natura 
of Cull en. But without supposing it to be aught distinct from 
the ordinary attributes of living matter, we sec its frequent opera- 
tion in the common performance of excretion; in the careful 
manner in which the noxious products of the body,and offending 
substances in food, are ejected from the system; in the flow of 
tears to wash a grain of dust from the eye; in the act of sneezing 
and coughing to discharge irritating matters from the air passages; 
and in the slower, more complicated, but not less obvious ex- 
ample of inflammation, effusion of lymph, and suppuration, by 
which a thorn or other extraneous object is removed from the 



17. This vis conservatrix (§ 16) is alive to the exciting causes 
of disease; and in persons in full health it is generally competent 
to resist them. How it resists them will depend on what they 
are. For instance: — Is cold the cause? It throws the blood 
inwardly; this, by increasing the secretions, and exciting the 
heart to reaction, establishes a calorific process, which removes 
the cold. Is the cause improper food? The preserving power 
operates by discharging this speedily by vomiting, or by stool. 
Is it a malarious or contagious poison? It carries it off in an 
increase of some of the secretions. But if this resisting power 
(§ 16) be weakened, locally or generally, or if the exciting cause 
be too strong for it, then the cause acts, and disease begins, 

(§ 15.) 

IS. In the cases hitherto noticed, predisponent causes consist 
in absence or deficiency of power (§ 16), rather than the exist- 
ence of any thing positive: but sometimes predispositions depend 



PREDISPOSING CAUSES OF DISEASE NOURISHMENT. 35 

on something positively wrong in the organization; and this 
error may be congenital, or hereditary, or acquired from previous 
disease. 

19. It must be observed that predisponent causes operate 
chiefly through the constitution, or some of its powers; hence 
they are often called constitutional or internal causes, in con- 
tradistinction to the exciting causes, which are more commonly 
external. But these terms are objectionable, because not always 
applicable. Sometimes the term jiredisposing is also inappro- 
priate, as in the following instance. Several persons are exposed 
to a malarious or infectious poison: some of these afterwards 
suffer much from fatigue or privation; they then begin to show 
the effects of the poison: others, who have not suffered this 
second trial, escape unhurt. The poison has entered the system 
of both; the last resist its influence; the subsequent weakening 
reduces the powers of resistance in the first class, and exposes 
the system to the exciting cause; but occurring after, it cannot 
be said to predispose. Hence, under such circumstance, the 
fatigue or privation is called the determining cause. 



SECTION II. 

PREDISPOSING- CAUSES OF DISEASE. 

20. It will be useful to illustrate, by a few examples and ex- 
planations, the chief predisposing causes of disease. In doing 
this, I shall enlarge on a list supplied in Dr. Alison's "Outlines of 
Pathology." 

I. Debilitating Causes of Predisposition are the most 
numerous of any. So we might expect from the fact that con- 
stitutional strength generally implies power of resisting disease, 
(§ 16, 17.) The weakness which renders the body liable to dis- 
ease is that especially which enfeebles the heart, and impairs the 
tone of the arteries: it is often accompanied with an unusual 
susceptibility of the nervous system, which increases the liability 
of the body to suffer. The following are the chief of this class. 

21. (1.) Imperfect nourishment, whether from defect in the 
quantityor quality of the food, or from incapacity of the digest- 
ive powers. This in itself may cause many diseases, particularly 
of ili«- digestive organs; but it also produces a liability to low 
jivi is ;mil inflammations, epidemic and contagious disorders. 
Thus the susceptibility of the body to infection when fasting, is 
generally acknowledged; and the rapid propagation of infectious 
diseases among an ill-fed population, such as the poor Irish, is 
too well known. 



36 PREDISPOSING CAUSES OF DISEASE. 

22. (2.) Confinement in impure air. The injurious effects of 
this are apparent in the pallid, cachectic complexion of the inha- 
bitants of crowded cities, oven those who live well and regularly. 
How do they contrast with the ruddy countenances of the hardy 
and coarsely-fed mountaineer! So do they also in their liability 
to diseases, particularly to those of the nervous and nutritive 
functions. 

23. (3.) Excessive exertion of mind or bod i/ without sufficient 
sleep. Exercise is beneficial to both body and mind; but when 
it exceeds what the strength can bear, or resl can recruit, the 
animal functions are exhausted, and Jose their balance, tone is 
impaired, nervous excitability takes the place of strength, con- 
gestions ensue, and various organs are on the brink of dii 

It is thus that the fatigued mind or body is peculiarly prone to 
snller from causes of disease. 

'J t. (4.) Long continued heat, particularly' when combined 
with moisture, (nut unrelieved hi/ the invigorating influence of 
occasional cold. The debilitating effects of thisagenl areremark- 
ably exemplified in warm climates and seasons. The muscles, 
and with them the heart and arteries, lose power and tone; 
vessels become relaxed: perspiration is profuse; and internal 
organs, especially the liver, are too much stimulated by blood 
thai has lost more than usual of its water, and less of iis oxygen. 
Hence die disposition to bilious and liver complaints, dysentery, 
and cholera. Overheated rooms ami excessive clothing like- 
wise predispose to disease by their weakening and relaxing in- 
fluence. 

(5.) Long continued cold, not sufficiently counteracted hi/ 
artificial protection and by muscular exertion. Cold applied 
occasionally, invigorates, because il is followed bya health 
action, in which the vital prop.. ,; and exalted. 

But when long continued, its sedative and debilitating .effects 
are permanent: it weakens the circulation, especially that of the 
surface, causes internal congestions, and directly lowers all the 
vital energies. Hence the. most malignanl forms of epidemic 
fever in this country are observed to prevail towards the cloi • of 
very severe winters; and all diseases may then assume a typhoid 
type. This is observed chiefly among the lower orders, whose 
means do not enable them to protect themselves sufficiently 
against the inclemencies of the season. We have before adverted 
to the striking manner in which cold disposes the body to suffer 
from malaria. 

26. (6.) Habitual intemperance with intoxicating liquors. 
There is probably, in this count) y. no source of disease more fertile 
than this. Beside many which it excites, it also predisposes the 
body to attacks of fever, erysipelas,- dysentery, cholera, dropsy, 



MIND EVACUATIONS— DEBILITY. 37 

rheumatic and urinary diseases; and if it do not increase the 
proneness to inflammatory disorders, the habit of intemperance 
certainly disposes them to unfavourable terminations, and causes 
many a victim to sink after accidents and operations, which would 
be comparatively trifling in a sober subject. Nor can we wonder 
at the pernicious effects of this kind of excess, when we consider 
the unsound state of function and structure which stimulating 
drinks induce, especially in the organs which they most directly 
affect, the stomach, the liver, and the kidneys. We shall soon 
have to explain how such an unsound state of these organs pe- 
culiarly impairs the powers of the body to resist or throw off dis- 
ease, (§ 17.) 

27. (7.) Depressing passions of the mind, such as fear, grief 
and despondency. Many are the instances in which numbers as 
well as individuals have escaped a prevalent disease, until de- 
pressed by some unhappy event or apprehension, and then they 
have fallen victims. Such was instanced in the ill-fated Wal- 
cheren expedition, and in many passages in the history of armies 
in pestilential countries. A defeat, a failure, or even bad news, 
made many succumb to the pestilence who had before escaped. 
It is a common remark, that when a contagious or epidemic dis- 
ease prevails, those who take most precautions frequently suffer, 
because they are timid and fearful, whilst the stout-hearted and 
reckless are unscathed. 

28. (8.) Excessive and repeated evacuations, either of the 
blood or of some secretion from it. The weakening effect of a 
large loss of blood needs no explanation: but the injurious influ- 
ence of habitual Losses, if they be more than the system can repair, 
is still greater; for the functions then become depraved, a state of 
cachexia as well as anamiia is induced, and a little cause may 
suffice to determine many states of disease. Various haemorrhages 
;iii(l discharges, menorrhagia, diarrhoea, and other fluxes, if in 
excess, reduce the powers of life, and the capacity to resist disease. 
No secretion, however, weakens so much or so irreparably, when 
in excess, ;is that of semen. In many of the lower tribes of ani- 
mals, the males live till they copulate, and then die: the repro- 
duction of the species is at the expense of the individual. That 
<nir species is not wholly exempt from this law of organized na- 
fcure, is apparent from the fact that immoderate venery is known 
to induce extreme debility and premature decay, and to dispose 
the body and mind to various diseases. 

-'.'). (9.) Previous debilitating diseases, and the treatment used 
to remove them. It is well known that the body is unusually 
liable to disorder dnrinL r convalescence from serious maladies. 
It i> weak in nil its parts; and improper food, exertion, excite- 
ment, ot exposure to cold, may readily produce the former or 
4 



38 PREDISPOSING CAUSES OP DISEASE. 

some new complaint. Hence convalescence from a seven 1 d ; 
is a condition of health that requires peculiar care. The func- 
tions are but just resuming their balance, and have neither the 

capacity to act nor the power of resistance which is the attribute 
of robust health. 

30. II. Hitherto we have considered only those circumstances 
which predispose to disease by their weakening influence, (§ Hi, 
17,20.) There are others of a somewhat opposite character, 
which favour the production of disease by vascular fulnkss or 
activity. Thus full living with insufficient exercise, and other 
causes of plethora, predispose the body to apoplexy, haemorrhages, 
and L r <>ni; and although it is doubtful that they increase the tend- 
ency to inflammation, yel theymake ii more intense when it does 
occur. So. also, undue fulness* of blood-vessels in a part, when 
insufficient to produce disease, renders the pari more liable to 
suffer from external causes. Thus the periodic determination of 
blood to the uterus and mammas renders them Liable to disease at 
that time. Violent exertion makes the muscles or their fasciae 
peculiarly liable to rheumatic inflammation on exposure to cold. 
Excessive indulgence in a stimulanl diuretic beverage, such as 
punch, renders the kidneys liable to disorder on exposure to cold. 
Inflammation or irritation of the intestines is not a common effect 
of cold, except when these viscera are under the exciting influence 
of a purgative. 

31. III. Proclivity to disease is not unfrequendy caused by 
previous disease, independent iy of the weakening influence 
before noticed. (§ 89.) This is particularly the case with some 
inflammatory and nervous disorders. Tims, a child who lias 
once had croup is very liable to its recjarrence. One attack of 
enteritis frequently predisposes to its recurrence. Convulsive 
disorders, such as chorea, hysteria, and epilepsy, are extremely 
apt to recur; and the longer they have existed, the more difficult 
are they to remove, and the more ready are they to reappear on 
the application of any exciting cause. This is what may be 
called a habit of disease, which it is most important to prevent 
There' can be little doubt that the previous attack in all such 
cases leaves some change of structure or function, (§ 18,) which 
constitutes the predisposition, although this change may elude 
our means of detection. 

32. Under this head we may arrange many constitutional 
predispositions to disease which are to be ascribed, not to a 
previous attack, but to the persistence in the system of a cause 
of that attack. Rheumatism, gout, gravel, many cutaneous 
diseases, dropsy, jaundice, and many others, may be quoted as 



ORGANIC DISEASE. 39 

examples. A person who has once suffered from any of these 
is very liable to a recurrence on the application of an exciting 
cause; and this is, because, although free from the first attack, 
he may not be free from some functional or structural imper- 
fection (§18) which was the predisponent to that attack, and 
which may again be brought into operation by the addition of 
an exciting cause. In most of these cases the constitutional defect 
is in some of the processes of assimilation or excretion, this defect 
being generally functional, but in some cases it is also attended 
with change of structure, especially in the great eliminating 
organs, the liver and the kidneys. When the tendency to the 
diseases under notice is acquired, it may be often traced to causes 
which peculiarly affect these organs, such as intemperance or 
irregularities of diet, and scarlet fever. 

33. Nor can we separate from this class of constitutional causes 
(§31) the predispositions to many structural diseases, such as 
tuberculous and malignant formations. Where such have once 
appeared, there is a tendency to the production of more, although 
this tendency may be latent until brought into activity by an 
exciting cause. In the following pages many arguments will 
be found in favour of the view that the disposition to these 
diseases is connected with' errors in the functions of assimilation 
and excretion, (§ 32.) 

34. IV. Organic disease already existing in the body, 
even when itself latent, often predisposes to other disorders, in- 
dependently of its weakening effect, (§ 20.) Thus tubercles and 
Other tumours, structural lesions of the heart and other organs, 
often induce irritations or obstructions of blood-vessels, which, 
if not themselves causing open disease, render them ripe for 
mischief inflicted by other causes. Thus a person on the occa- 
sion of violent bodily or vocal exertion is seized with profuse 
spilling of blood, which causes his death: on opening the body 
many tubercles are found in the lungs, although there had been 
no obvious symptoms of their existence before the violent effort. 
Again, disease of the heart causing accumulation in the veins 
often Leads to congestion of the lungs and liver; and it may only 
require the addition of an exciting cause, such as sudden exer- 
tion or an excess in diet, to bring about an attack of asthma or 
jaundice. 

35. The predisposing causes hitherto considered may be called 
accidental or acquired. There are others which are born with the 
individual; and others which arise from circumstances of age or 
growth. All these may be* supposed to depend on something de- 
fective or ill-balanced in the organization, (§ 18,) which is in- 
sufficient to manifest itself until wrought upon by an external 
exciting cause. 



40 PREDISPOSING CAUSES OF DISEASE. 

36. V. Of the predispositions horn with the individual, the 
most generally acknowledged is hereditary tendency to dis- 
ease. It is well known that scrofula, gout, leprosy, epilepsy, 
mania, asthma, blindness, and clearness, run in families. That 
this depends on individual peculiarities transmitted from parents 
to offspring, appears from the fad that all children do not partake, 
or not alike, of the disposition. Nay, sometimes a whole genera* 
tion is passed over, and the disease appears in a third. So too 
we see external organization, family likeness, differently stamped 
on different children of the same family. 

It must nol be supposed that hereditary proclivity to disease 
commences at birth. In a few instances il is congenital; tail in 
the greater number it is developed by growth or seme other cir- 
cumstances in life. Gout, for example, is acknowledged to be 
hereditary. A parent has it in middle or advanced life: bis son 
do not get it until about the same period, sooner or later, accord- 
ing to whether he lives lively or not. Here is something trans- 
mitted from father to son, yet not manifested in the son tor forty 
or fifty years. 

37. VI. Frequently but nol essentially connected with heredi- 
tary conformation is the peculiarity of constitution culled tem- 
perament, which certainly predisposes to particular diseases. 
Temperament is constituted by a predominance or defed oJ 
function, (9.) 

3S. Thus the sanguine temperament implies an activity of the 
system which circulates red blood, and ;i rich proportion of red 
particles, manifest in the excitable pulse and flushing cheek of 
those of this temperament; and further evinced m their quick 
movements and lively disposition. This temperamenl gives a 
sition to inflammation', determination of blood, and active 
haemorrhage, (30.) 

39. In the hi/ions or melancholic temperament, which is com- 
monly met with in persons of dark complexion and gloomy dis- 
position, there is probably a defective action in some of the biliary 
or digestive organs, which are therefore the more liable to de- 
rangement, (9.) 

40. In the phlegmatic or lymphatic temperam< tit, which ge- 
nerally occurs in those with weak pulse and languid circulation, 
cold extremities, and pallid skin, — there is a deficiency of red 
blood and of vascular action and tone, (§ 9,) and the' proclivity is 
to watery rlnxes, dropsy, and other chronic affections. 

41. The nervous temperament is externally manifest only by 
agitation or hurry of manner: it seems to depend on an exo 
want of proportion of some properties of the nervous system, 
(§ 9,) and it predisposes to the disorders called nervous, such as 



AGE INFANCY CHILDHOOD. 41 

hysteria, nervous pains, spasms, &c. These temperaments may- 
be variously combined. 

The term diathesis is often used to express a particular morbid 
tendency; thus we hear of the inflammatory diathesis, the scrofu- 
lous diathesis, &c. It is merely a name, signifying predisposition, 
without affording any clue to its true cause. 

42. VII. The last head of predisponent causes to be noticed is 
age. The several changes in organization as well as in external 
circumstance which the animal frame undergoes at different peri- 
ods of life, may naturally be expected to be attended with corre- 
sponding proclivities to disease. I proceed to enumerate a few of 
these, premising that some of the examples may be entitled to 
rank under the head of exciting causes of disease, as well as under 
that of predispositions. 

43. (1.) In early infancy, the low calorific power of the body 
disposes it to suffer from the bad effects of cold, (§ 17,) whence 
the tendency to visceral inflammations. The skin is particularly 
liable to various eruptions in consequence of its tenderness and 
the new and drying medium in which it is placed. The redness 
of new-born children is obviously the result of the action of the 
air; it is often a vivid erythema, followed by desquamation of the 
cuticle, and a yellow stain of the skin from extravasated hasma- 
tosin, which is erroneously thought to be a kind of jaundice. 
Strophulus and other papular eruptions often succeed. The com- 
para lively virgin state of the alimentary canal at birth renders it 
peculiarly susceptible of disorder; and a similar trial may occur 
at the period of weaning; hence arise diarrhoea, vomiting, colic, 
waterbrash, atrophy, and other ailments connected with disorder- 
ed digestion. 

The brain, excited by the novelties of the external world, be- 
comes rapidly developed, and in its increased activity and growth 
is liable to various diseases, (§ 30,) hence the proclivity to hydro- 
cephalus, convulsions, &c. 

The process of teething adds an irritation, which, by its influ- 
ehce on the head, the bowels, and the air passages, disposes them 
to disorder. 

44. (2.) Childhood, or the age from infancy to puberty. The 
functions most active are those which administer to growth: the 
organs Of digestion and assimilation are therefore obnoxious to 
disorder, (§ 30;) hence derangements of the stomach and bowels, 
worms, infantile remittent, &c. 

The activity of the nutritive function gives a preponderance to 
the fibrinous or proteine constituent of the blood; and inflamma,- 
tions which may occur arc often" attended with the effusion of 
4* 



42 PREDISPOSING CAUSES OF DISEASE. 

much plastic or albuminous matter; hence the products of croup, 
tubercle, mesenteric disease, &c. 

The natural mobility (or activity of the excitomotory system) of 
childhood predisposes to chorea and kindred affections, (§ 30.) 

45. (3.) Puberty brings with it many morbid susceptibilities, 
chiefly in the female sex, in which the important function of 
menstruation is to be established. Many and serious are the 
evils that are liable to be produced by external causes, which 
check the development of this function. So also when established, 
this function has its pervous as well as ils vascular relations; 
and where it is irregular or disordered, a predisposition is given 
to many maladies, affecting the blood-vessels and their contents, 
the secreting organs, and the nervous system. 

46. (4.) At the termination of growth, there is another criti- 
cal period. The cessation of that appropriation of nourishment 
for the increase of the body, that had hitherto been going on, may 
cause fulness, and a disposition to haemorrhage and inflammation 
in the more robust; and in the cachectic, to morbid depositions, 
especially of the tuberculous kind, (§ 17.) 

47. (5.) Adult age can hardly he said to predispose to any dis- 
eases, unless it be those arising out of occupation, and those con- 
nected with the generative function, for which this age is obviously 
the natural period. When this function fails, at what is termed 
the change of life, there is a remarkable tendency to various dis- 
eases, generally connected either with vascular plethora, or with 
morbid growths of various kinds, particularly in the uterus, ova- 
ries, mamma-, testes, prostate, rectum, &:c. 

48. (<>.) As old uu;e app bits are more established; 
and unless they are such as are calculated to maintain the balance 
of the functions, (§ 6,) they gradually affect the organization, and 
accelerate those changes in the fabric, by which our existence is 
limited to a span of years. It would occupy too much space to 
enter into the details of all these changes, but some of the prin- 
cipal may be briefly noticed. 

The nutritive function becomes impaired; and instead of 
muscles, iat, and integuments being nourished in the equal pro- 
portions that give beauty as well as strength to the form in early 
adult age, the deposition of tat becomes scanty, partial, or in 
excess; the muscles become thinner and more sinewy; and the 
integuments are loose and wrinkled, or fat and flabby. The blood- 
vessels, too, lose their proportion and mutual adaptation. The 
arteries become less elastic, and transmit the heart's pulse un- 
softened to the capillaries. The veins become distended and 
tortuous; particularly in persons whose employment has required 
much muscular exertion. The capillaries have no longer the 
vital sivsceptibility which is evinced in the blush of youth. This 



EXCITING CAUSES OF DISEASE. 43 

altered proportion of the blood-vessels brings with it morbid 
tendencies, the nature of which will depend much on the great 
moving power, the heart; now more than ever the prime agent 
in the circulation. If the heart be moderately strong, a fair 
balance may long be sustained; although haemorrhoids, varicose 
veins, and such irregularities from local obstructions, may occur. 
If the heart be too strong, (which is often the case after a life of 
much muscular exertion,) the small arteries may suffer from the 
imsoftened force of its pulses, particularly in the brain, and there 
is a liability to apoplexy or palsy: and in mucous membranes 
there is a disposition to active fluxes and haemorrhages; hence 
catarrh, asthma, and affections of the urinary organs. If the 
heart be weak or diseased, there will be imperfect circulation 
and tendency to venous congestions, dropsical effusions, imperfect 
and disordered secretions, and a general failure of all the functions, 
which depend on a sufficient supply of arterial blood: hence may 
arise diseases of the liver, stomach, kidneys, lungs, and in fact 
any of the viscera: in extreme cases the lower extremities actually 
die for want of circulation. 

If instead of the organs of circulation we were to take the 
alimentary, the respiratory, or the urinary apparatus, Ave should 
here too find changes induced by age, which show the necessarily 
limited time that man's organization is intended to last. Old 
age is thus attended with increasing infirmities and liabilities to 
disease, (§ 16, 18.) The very strength and activity which some 
functions retain, may, from their partiality, endanger life; and 
their gradual and more equal failure degrades the physical and 
often the mental frame of man to a lower scale of existence, until 
he sinks into second childhood, dotage, and imbecility. 



SECTION III. 

EXCITIXG CAUSES OF DISEASE. 

49. We now pass to the consideration of exciting or occasional 
causes of disease, or those circumstances and agents which, 
operating on the body, especially when predisposed, (§ 14,) may 
excite disease in it. It has been stated before, (§ 11, 15,) that 
certain powerful agente, such as irritants or poisons, pretty surely 
c.ii e disease, independently of constitution or predisposition; but 
constitution or predisposition may much modify the character of 
this disease in different cases; and where tin; agents are less 
powerful, ;is in (he case of common causes of disease, the effects 
will depend Mill more on the predisposition, and maybe null 
where this is not strung, (§ 15, 19.) 



44 EXCITING CAUSES OF DISEASE. 

50. Exciting causes may be divided into the cognizable and 
noxcognizable. The former class comprehend physical and 
mental agents, of whose existence we can take cognizance, inde- 
pendently of their operation in producing disease; thus cold we 
know by its effect on our instruments and sensations; muscular 
exertion by our witnessing or performing it; and mental emotion 
by our consciousness of it. The noncognizable causes, on the 
other hand, elude our senses, and we infer their existence only 
from their morbific effects: thus malaria and infection we know 
by no other property but that in question. The subjoined table 
includes both classes. 

"1. Mechanical. 

2. Chemical. 

3. Ingesta. 
Cognizable J 4. Bodily exertion. 

Agents. i 5. Menial emotii 

G. Suppressed or defective evacuation. 
| 7. Excessive evacuation. 
1.8. Temperature and changes. 



Exciting Causes 

of 

Disease. 



!1. En. 
2. Epi 
3. Infc 



Noncognizable N i' Endemic 



I. COGNIZABLE AGENTS. 

51. (1.) Mechanical causes, which injure structure, or impede 
or derdnge function. Besides the obvious instances of tearing, 
cutting, pinching, striking, and straining, which produce at once 
diseases which fall tinder the province of the surgeon, the 
physician Ends many mechanical causes of diseases winch he has 
to treat. Long-continued pressure of articles of clothing may 
produce disease. Tight neckcloths may produce apoplexy, by 
impeding the flow of blood front the head. Tighl stays may cause 
fainting, by pressure on the heart and great vessels; or colic and 
costiveness, by obstructing the free passage through the great 
intestines. Pressure on the epigastrium by sitting at a desk after 
a meal, may cause indigestion. Long continuance in one po- 
sition, whether standing, sitting, or Lying, will partially obstruct 
circulation and innervation, and produce swelling and paralysis 
of the lower parts, or those beyond the seat of pressure, and in 
time may cause inflammation and death of the parts pressed 
upon. Mechanical causes also operate within the body. A 
stone in the bladder irritates by its mechanical properties, espe- 
cially if it be of the mulberry kind; or it mechanically stops the 
flow of urine: so also may a gall-stone that of the bile. The in- 
testinal caual is often mechanically stopped by hardened fasces, 
and irritation and inflammation may ensue. The stomach is 



MECHANICAL CAUSES CHEMICAL CAUSES. 45 

often irritated by the mechanical qualities, bulk, hardness or as- 
perities of its contents: thence may ensue vomiting, indigestion, or 
inflammation of the organ. The air-passages of needle-pointers, 
stone-masons, &c., are irritated and inflamed, and at length altered 
in structure, in consequence of the mechanical action of particles 
of stone or other substances, which these men are continually in- 
haling in the course of their employment. 

Instances are endless; and the further effects of disease are also 
in great measure mechanical. For example: the influence of 
tumours, of diseases of the heart and vessels, the lungs and air- 
passages, intestines, and urinary apparatus, injuries and diseases 
of the bones and ligaments, &c. &c, is hi great part mechanical, 
interfering with the natural mechanism. 

52. Besides their simple mechanical effects on structures and 
functions, (§ 51,) some mechanical injuries, when extensive, 
directly depress the vital powers; thus crushing or tearing off a 
limb, or a blow on the epigastrium, causes fainting and extreme 
weakness of the heart's action, and may thus cause death. 
Slighter mechanical injuries are causes of irritation or excitement, 
which may be local or general, according to circumstances. 

53. (2.) Chemical causes of disease are even more varied than 
mechanical, because chemical agents are more numerous. We 
are acquainted less with the chemistry than with the mechanism 
of the animal body, and therefore can less distinguish causes 
which act by chemical properties from those which have com- 
plex relations to vital properties. But we recognize chemical 
irritants in acids and alkalies and many salts, whether applied 
Liquid, or inhaled in form of gas or vapour. So what are called 
chemical poisons, such as corrosive sublimate and other metallic 
salts, the strong acids and alkalies, iodine, chlorine, &c, produce 
disease by their known powerful chemical affinities, which tend 
to decompose tissues and disorder functions. 

We cannol doubt that many of the matters which cause dis- 
in the alimentary canal, do so by virtue of their chemical 
qualities. The process of digestion, although always in part 
chemical, is so under the superintendent influence of a superior 
vital power: no sooner does this power fail, or the chemical 
agencies or decompositions become too strong for it, than we 
have fermentation and putrefaction, which- cause eructation of 
gas or sour Liquid from the mouth, and there may follow the dis- 
charge of ill-coloured and unusally foetid matter by stool: then, 
tn... may arise a number of disorders, which may in greal part be 
referred i<> the influence of these injurious chemical processes. 

There can he little doubt, too, thai the chemical composition of 
the differenl constituents of the body is subject to variations which 
may themselves become causes of disease. The altered slate of 



46 EXCITING CAUSES OF DISEASE. 

the blood which we see in malignant cholera, scurvy, typhous and 
inflammatory fevers, is a proof that there is a great difference in 
this fluid; but how far this is a simply chemical, or a vital and 
chemical change, is as uncertain as is the question of tin- vital 
properties of the blood in health. 

54.(3.) The solid and liquid ingesta area fertile source of 
disease, and in various ways. Their mechanical and chemical 
properties have been already noticed, (51, 53.) But further, the 
ingesta may cause disease — 

a By non-alimentary matters acting injuriously. 

j3 By aliment defective, or ill proportioned in quantity. 

y By aliment defective, or excessive in quantity. 

55. ( a ) Of the non-alimentary matters contained in the ingesta, 
salt, spices, pickles, and other condiments, and spirituous or fer- 
mented liquors, are frequent exciting causes of disease. They are 
all more or less irritating or stimulating to the digestive apparatus: 
audit' used indiscreetly may induce inflammations, congestions, 
and functional disorders of these organs, and. in some instances, 
irritation of other parts, and of the whole system. Sail in excess 
irritates the stomach, causes feverishness with thirst, and, accord- 
ing to Liebig, impedes the deposition of fat. Animals will not 
fatten on salt food;— a hint for the corpulent. 

56. But the operation of intoxicating Liquors is more extended: 
being soon absorbed, their stimulant action is directly felt on dis- 
tant parts, especially on the vascular and nervous system. Being 
absorbed by the veins, they pass by the portal vein into the liver, 
the nmction and structure of -which is particularly apt to suffer 
when spirits have been lively indulged in. So too the kidneys, 
which are the natural emunctories through which such extrane- 
ous matters are eliminated from the system, are often over-stimu- 
lated, and are injured in their secreting power, and ultimately in 
structure also. The heart and vessels are over-excited al the time, 
and afterwards lose their tone: and the processes of secretion and 
nutrition become variously disordered. The nervous system is an 
especial subject of the disordering influence of intoxicating liquors. 
A large quantity taken at a time is a narcotic poison, inducing, 
first, cerebral excitement, then intoxication, and insensibility. The 
functions of the brain are more or less impaired, and at last those 
of the spinal marrow; and if the influence be insufficient to stop 
respiration, yet it may be imperfectly performed, and congestions 
are formed in the brain and other organs. Hence, apoplexy, 
palsy, phrenitis, delirium tremens, may follow, and the whole 
frame may suffer from the effects of the poison. Even when less 
excessive quantities are taken, and their first effect is mere intoxi- 
cation, the headache, sickness, and inappetency, and the feelings 
of wretchedness and depression which often "ensue, sufficiently 



INGESTA, NON-ALIMENTARY. " 47 

prove that disorder has been produced, and that such artificial 
excitements cannot be abused with impunity. 

Yet these and other adjuncts to food, when taken with modera- 
tion and discrimination, often prove useful, to aid the digestion 
where it is weak, and to counteract various exhausting and de- 
pressing influences, which are frequently arising out of the artifi- 
cial condition and employments of society, especially in large 
towns. Total abstinence, therefore, is preferable to moderation, 
only because it is morally easier to practise, not because it is more 
salutary in its physical effects. 

57. Disease may be excited by unwholesome articles with which 
the food is adulterated. To this class of causes belong various poi- 
sons; the operation of some of these will be noticed under the head 
of causes of death: but for further details, works on toxicology 
and materia medica must be consulted. There are .some noxious 
matters occasionally mixed Avith food, which gradually produce 
deleterious effects. Thus salted provisions too long used will 
cause scurvy; ergotted corn has been known to produce dry gan- 
grene. Lead gradually introduced causes constipation, colic, 
paralysis, and atrophy. I fear, too, that under this head we must 
confess that medicines are fertile sources of disease, and that, not 
only when injudiciously administered; the remedies necessary 
to cure or relieve many diseases are not uncommonly necessary 
evils; they remove one disorder by inducing another, and are en- 
titled to rank among the causes of disease. 

58. (,3) Aliment ill proportioned in quantity is another article 
of the ingest a that may cause disease. Man is by nature and 
habit an omnivorous animal; and in general his health is best 
maintained by mixed proportions of animal and vegetable food. 
The insalubrity of the simpler constituents of food, when separate, 
even those supposed to be most nutritive, has been well shown 
by the numerous experiments of Majendie, Gmelin, and others. 
They fed dogs, geese, donkeys, and other animals, on articles 
which are generally considered highly nutritive, as sugar, gum, 
oil, or butter: the animals died with symptoms of. starvation 
almost as soon as if they had been kept without food. Even 
bread, when too fine, is insufficient for nutriment. A dog fed on 
pure white bread lived only fifty days, whereas another fed with 
the coarsest brown bread was well nourished, and seemed capa- 
ble of living an indefinite period. According to the researches of 
a commission of the French Institute, (the report of which was 
published in L841,) gluten, or vegetable albumen, is the only sim- 
ple principle which will alone maintain Life* and tine nutritious 
qualities of vegetable food depend chiefly on the quantity of this 
azotized principle which they contain. Bread may therefore well 
be called tbe Staff of life. 



48 EXCITING CAUSES OF DISEASE. 

Animal albumen and fibrin require mixture with vegetable 
matter to make them properly nutritious as well as wholesome; 
and gelatine and oily matters arc still less available for nourish- 
ment without much combination. 

59. Liebig has recently advanced sonic novel views with re- 
gard to the purpose of the different proximate elements of food. 
He considers that the albuminous principle alone nourishes the 
body; all other proximate elements go to supply the excretions; 
their carbon and hydrogen being united with the oxygen absorb- 
ed hi respiration, and thrown off in the form of carbonic acid and 
water: and the nitrogen with the remainder of hydrogen and car- 
bon being separated in the constituents of bile and urine. The 
union of the combustible constituents of the food with the oxygen 
inhaled, he considers to be the great source of animal heat, which 
is raised by oily or saccharine matters in the food, together with 
the increased supply of oxygen afforded by cold air or exercise. 
Thus the Laplander cuts train oil for fuel; whilst the [talian, under 
a sunny sky. delights in maccaroni, which nourishes without heat- 
ing him. U' the inhabitant of a warm climate indulges in rich, 
greasy food, he loads his blood with hydrocarbon, which the 
scanty oxygen of the rarer air which he breathes is insufficient to 
remove; the liver is overtasked to eliminate the superfluous mat- 
ter, and is therefore liable to derangement. These and other views 
of this distinguished chemist are highly interesting, bul as yet 
they seem too speculative to become the basis of patholi 

Ing. 

60. The views of Dr. Front' on the due proportion of ali- 
mentary matters, although also in some measure hypothetical, 
are more in accordance with common experience. He considers 
milk to he the great prototype of all food: as its nutritious part 
consists of albumen, oil, and siiL r ar, so all our wholesome meals, 
or artificial combinations of food, comprise these three ingredients; 
albumen being isomeric with fibrin and gluten, (that is, identical 
in ultimate composition,) and starch with sugar. 

61. Every day's experience may teach us that disorder is apt 
to occur if we do not duly proportion the articles of food: thus if 
Ave take too much butter or fit. we become sick and bilious: if 
we subsist too much on farinaceous food, we become costive, for 
want of bile; if we eat meat too freely, we become bloated and 
heated, the urine becomes high coloured, and if we persist, we 
may become the subjects of plethora, inflammation, srout, or cal- 
culous disorders: if, on the other hand, we feed too exclusively on 
vegetable food, we lose cokmr and muscular strength. The ap- 
petite and taste generally instruct us pretty safely as to the best 

" On Stomach and Urinary Diseases." 1840. P. xvi. 



DEFECTIVE NOURISHMENT VIOLENT EXERTION. 49 

proportions of different kinds of food; but then they must- not be 
perverted and pampered by condiments and recherche modes of 
cooking. These are expedients'to coax and deceive the appetite 
and taste; and if these guardians of the 'nutritive department are 
cheated, it is no wonder that the department becomes deranged. 

62. ( y ) Aliment may be excessive 'or deficient in quantity. 
Sometimes the appetite is inordinate; more frequently it is pam- 
pered; in either case, mare food is taken than the expenditure of 
the system- requires. . If the digestive organs fail in appropriating 
the nourishment, they become distended, irritated, and otherwise 
disordered by what they cannot digest. If they are strong and 
digest the excess, they send too much chyle into the blood, and- 
this may cause plethora, apoplexy, gout, gravel, or some con- 
gestive or inflammatory disorder to which the individual is pre- 
disposed,^ 14.) 

63. Defective nourishment may excite various ' disorders. In 
the extreme case of privation of food the cravings of hunger are 
alternated with nausea and' a sense of sinking; then follow fever, 
delirium, and general disorder, of both body and mind, with in- 
creasing feebleness. It is a . curious fact, that in this state the 
stomach becomes inflamed; probably from the irritating action of 
its .secretion .on its unrelieved vessels.. Even, in less degrees of 
abstinence, enjoined in -the treatment of disease, symptoms of 
vascular and nervous irritation often arise -in the midst" of general 
weakness. By many practitioners of the Broussaian school, these 
symptoms are erroneously taken as indications for an increase of 
the antiphlogistic plan, when a judicious return to nourishing food 
will really prove the best cure. Deficiency of food, if long con- 
tinued, causes general weakness of all the functions and wasting 
of all the textures. The blood becomes thin and easily extrava- 
siitcd; the gums spongy and bleeding; the legs oedematous; diar- 
rhoea -often occurs; ulcers appear in the cornea and other parts; 
a state of scurvy or cachexy is induced, from which, if advanced, 
I u i impro ved diet may now fail to restore. In less extreme cases, 
poor living may excite scrofulous and tuberculous disease, and. 
< it I it kindred forms of degeneration of organs. The bad influ- 
ence of poor living is much more felt in those who are confined 
in close habitations, as in prisons, poor-houses, the cabins of ships, 
and besieged towns; than in those who are at large, (§ 22:) and 
it is under such circumstances that the insalubrity of some kinds 
of food, however nutritious, becomes apparent. Thus even bread 
wiih meat or broth will not exclude scurvy; but a sufficient ad- 
dition of fresh vegetables, and even of potatoes, prevents this 
disease from occurring.— (Dr. Baly, Med. Gaz., Feb., 1843.) 

G4. (1.) Violent bodily exertion of various kinds is a common 
5 



50 EXCITING CAUSES OF DISEASE. 

exciting cause of disease. General muscular efforts, as in run- 
ning, walking up hill, rowing, &c, hurries the movement of the 
blood back to the heart, and resists its distribution through the 
arteries in such a degree that the heart, the lungs, the brain, and 
other organs, have an unusual pressure of blood upon them, 
(§51.) 

The heart is excited to inordinate action, is often strained and 
distended, and its function, or even its structure, and that of the 
great vessels, may be impaired in consequence. This is espe- 
cially apt to happen if there is any thing already imperfect in the 
structure of the organ, its valves or vessels; and there are natu- 
rally very various degrees of perfection and strength in these 
parts. 

The brain is particularly liable to suffer from violent exertion, 
especially if joined with a stooping or constrained posture; for its 
vessels are not, like those of the limbs and trunk, supported by 
muscular pressure upon them, and the excited heart can there- 
fore send its blood into them with more force. Hence giddiness, 
noise in the ears, deafness, defective vision, convulsions, palsy, 
and apoplexy, have been brought on by violent exertion. 

The lungs are also apt to suffer; for the blood being returned 
to them faster than they can arterialize it, they become greatly 
congested; hence cough, dyspnoea, haemoptysis, or inflammation 
of the lungs, may ensue; and the texture of the Iiiiilts may also 
sustain injury in consequence of the violent strain to which it is 
subjected by the increased exertions for breath. 

Other internal organs sometimes are disordered by tbe blood 
thrown or retained in their vessels by the pressure of externa] 
muscular action. Derangement of the liver, haematemesis, 
haemorrhoids, and haematuria, have been brought on by such a 
cause. The sharp pains or stitches felt in the sides or abdomen 
on running fast are commonly supposed to be in tbe liver or 
spleen; but more probably they are spasms pi the intestines — 
temporary colic, produced by irregular pressure on them, when 
their sensibility is raised by the blood unduly thrown into them. 

Some kinds of muscular exertion peculiarly affect certain or- 
gans. Thus loud reading or speaking, or blowing wind instru- 
ments, especially try the. organs of respiration and the voice, and 
may cause haemorrhage, inflammation, and various diseases of 
these organs. Excessive or rough riding or leaping may injuri- 
ously affect the kidneys and organs of generation. Straining to 
lift a* heavy weight, or at stool, or in any continued effort, which 
implies holding the breath, endangers the structure of the vessels 
of the chest and brain, on which there is no equally counteract- 
ing muscular pressure. 

65. Bodily exertion may also cause disease by its exhausting 



MENTAL EMOTIONS. 51 

effects. In extreme degrees this exhaustion may amount to syn- 
cope, and even death: short of this, it may cause great weakness 
of muscles and of the heart, with corresponding depression of 
other functions. A low typhoid or adynamic fever sometimes 
follows prolonged fatigue. In other cases, giddiness, nausea, loss 
of appetite, indigestion, costiveness, amenorrhoea, and other vari- 
eties of injured function. 

66. (5.) Strong mental emotion, or acute sensation, is a com- 
mon cause of disease. Closely knit together as the mind and 
body are — so closely, that their great common organ, the nervous 
system, seems to have double offices for both — it is not surprising 
that they should ever be ready to affect each other, and that 
when the impression is strong, the affection should not be slight 
or transient. The heart most remarkably suffers from such 
causes. Thus a sudden shock, whether of grief, surprise, fear, or 
even joy, may cause fainting, partial suspension of the action of 
the heart; nay, even death has ensued; and the expressions 
"frightened to death," and "killed with joy," are not always 
mere figures of speech. Sudden acute pain often causes fainting. 
Palpitation and irregular action of the heart are very common 
effects of emotions. 

Other parts also suffer from strong moral impressions. Spas- 
modic asthma and spasmodic affections of the throat are some- 
times thus induced. Apoplexy, palsy, inflammation of the brain, 
epilepsy, and insanity, have been caused by excessive anger, 
terror, surprise, and joy. 

Very commonly, mental emotions affect the secreting organs, 
and especially the functions of the alimentary canal. A piece of 
very bad news takes away appetite, or impairs digestion. Fright 
or anxiety often loosens the bowels, or brings on a bilious attack, 
or jaundice. The uterine periodic function is remarkably subject 
to the influence of moral emotions, and many of its disorders may 
often be traced to this source. 

The slower emotions of. the mind and over-exertion of its 
faculties are also exciting causes of disease. Long-continued de- 
pression <>r anxiety sometimes induces dyspepsia, costiveness, or 
diarrha'a, asthma, and functional disorders of the heart, monor- 
rhagia, and dysmenorrhoea; and in time structural diseases of the 
same parts occasionally follow these functional affections. Over- 
exertion of the faculties, or excitement of the passions of the 
mind, is chiefly felt in its own functions, or in its own organ the 
nervous system. Hence may arise congestions of the brain and 
exhaustion of nervous power, with giddiness, stupor, headache, 
dull and disordered sensation, and even apoplexy and palsy. Or 
the disease may be inflammatory, with symptoms of irregular 



52 EXCITING CAUSES OP DISEASE. 

excitement, nervousness, delirium, tremor, convulsion, partial 
paralysis, &c Sometimes the effects of excessive mental exer- 
tion or moral emotion are apparent only in the phenomena of the 
mind, the powers of which are injured or disordered, and various 
forms of insanity are produced. When we consider the variety 
and amount of lood and condiment, employment and excitement, 
that pass into the minds of persons in the busy and worrying 
scene of civilized life, it is not extraordinary that the mind, as 
well as the digestion, or other function, should occasionally be dis- 
ordered by such causes. 

67. (6.) Diseases are frequently excited by the retention, dimi- 
nution, or suppression, of evacuations, natural or habitual, 
especially if the change be sudden. The operation of this 
is somewhat diversified, causing disease, some by the positively 
noxious influence of matter retained in the system, which is the 
case of the excretions of urine and faeces; others, by causing ful- 
ness of the vessels, and the various disorders which this may in- 
duce. To the latter cases belong Lppn ssion of haemor- 
rhages, or other discharges which have become habitual. 

The matter of alvine and renal excretions is essentially perni- 
cious, and cannot belong retained even in their natural reposi- 
tories without causing mischief. Faeculenl matter, when it has 
reached the large intestine, is still acted on by the absorbentSj 
which take up its more fluid parts,and with them, if long re* 
tained, foetid matter, which ought to be excreted. The solid re- 
sidue becomes hard and scybalous, and may remain lodged in 
the cells of the colon, a cause of irritation, distension, and ob- 
struction, (§ 51.) Sometimes the system suffers before the intes- 
tine itself; at length, however, or sometimes al first, this part 
becomes irritated, colic, diarrhoea, and inflammation, may ensue 
— nay, in some instances, where efficient remedies have been 
neglected, even ulceration and other structural changes take 
place, before the offending matter has been dislodged. 

The retention of urine has even more pernicious effects. Be- 
sides mechanical distension, and irritation, and rupture, which 
may follow from the constantly accumulating secretion, (§ 51,) 
the fluid is partially reabsorbed, giving a urinous smell to the 
breath and perspiration, and sometimes causing typhoid symp- 
toms, which in extreme cases prove fatal, with delirium or con- 
vulsions, and coma; and effusions of serum, containing urea, are 
found in the brain, chest, and other parts. These are effects 
more commonly of suppression than of mere retention; but, in 
fact, suppression often follows retention: the retained urine is 
prone to decomposition, (§ 53;) highly irritating and offensive 
matters are produced, which cause injury to the bladder, rapidly 



DEFECTIVE SECRETIONS EXCESSIVE EVACUATIONS. 53 

extending up the ureters to the kidneys, whose function then 
becomes impaired or suppressed. 

68. The preceding are exreme results; but the attentive observer 
will find that smaller degrees of the same causes, insufficient 
secretion, or insufficient evacuation of excrementitious matters, 
are among the commonest sources of disorder; and it is by a 
proper restoration of these functions that the almost universal 
domestic remedies, as well as the common pills and draughts of 
the surgeon, prove so useful in preventing as well as in removing 
disease. 

Numberless maladies arise from suppression or irregularity of 
the catamenial discharge; and diseases are not unfrequently ex- 
cited or rendered active at the period of its total cessation. The 
same may be said of the secretion of milk. The disorders which 
these produce are commonly connected with local or general ple- 
thora. 

69. An artificial or diseased discharge or secretion, as that of a 
seton or issue, or from an ulcer or diseased membrane, or an un- 
naturally profuse flow of an ordinary secretion — such as looseness 
of the bowels, if so long established as to have become habitual 
— cannot be suddenly suppressed without great risk of exciting 
disease. The same may be said of habitual haemorrhages, as from 
the nose or rectum, and of the practice of periodical blood-letting. 
The maladies which result will vary with the predisposition; but 
generally they are of the nature of local or general vascular ful- 
ness, or some disorder of secretion or of the nervous system, arising 
from disturbances in the circulation. As examples may be named 
— congestion of the brain, apoplexy, congestion of the liver, va- 
rious haemorrhages and inflammations, gout, epilepsy, palsy, hys- 
teria, hypochondriasis, mania, &c. 

The suppression or too rapid removal of some cutaneous erup- 
tions may be appended to this class. The diseases which it ex- 
cites are sometimes inflammatory or profluvial, as gout, rheuma- 
tism, diarrhoea, &c; sometimes more nervous, as chorea, epilepsy, 
asthma, dyspepsia, hysteria, &c. 

70. (7.) Opposed to the group we have just considered, is ex- 
cessive evacuation or loss either of blood or of some secretion. 
This was formerly noticed (§ 28) as a cause of debility, which 
predisposes to other diseases; but if the loss be great or sudden, 
it may produce immediate disease. A certain fulness of the heart 
and blood-vessels is required for their healthy functions, as well 
as for those of all the organs which they supply. If a moderate 
quantity of blood be suddenly withdrawn, or a large quantity less 
suddenly, the heart's action will be impaired, rendered irregular, 
and may he interrupted, and the brain not receiving a supply 

5* 



54 EXCITING CAUSES OF DISEASE. 

sufficient for its functions, there may be fainting, with loss of con- 
sciousness, accompanied or followed by disordered function, palpi- 
tation, delirium, convulsion, or by death. The sudden impres- 
sion in these cases is exercised more on the bruin than on the 
heart; for these effects may be induced by the loss of a much 
smaller quantity of blood in an erect or sitting posture than in a 
horizontal posture. Similar results have been found to ensue from 
the sudden removal of pressure from the vessels in any consider- 
able part of the body, as by the discharge of the fluid of ascites, 
or by enclosing a limb in an exhausting tube. (Dr. Arnott.) Lower 
mentions a ease of extensive varix (enlargement) of the veins of 
the Lower extremities, in which the patient could not stand with- 
out tainting, until the legs were bandaged. In these cases, much 
of the blood, although not removed from the system, gravitates 
into vessels, where it becomes unavailable for the general circu- 
lation. The fainting which occurs in these cases is called cerebral 
syncope, because the functions of the brain are suspended, con- 
sciousness is lost before the heart's action is interrupted; but the 
disorder of the brain reacts on the heart, and adds another in- 
fluence to impair its action also. This is Dr. Alison's explanation. 
On the other hand, if the haemorrhage is gradual, and tin* posture 
horizontal, other functions fail before the consciousness is lost — 
the chief symptoms being "feebleness of muscular action, paleness 
and collapse of the countenance, coldness, beginning at the ex- 
tremities, cold sweat, beginning on the face, the pulse impercepti- 
ble," and the heart's action becoming so. The true nature of these 
effects, and of the reaction and nervous symptoms with which they 
are often followed, will be considered hereafter in connection with 
the subject of anaemia. 

Not only blood-letting, but other evacuations, purging, sweat- 
ing, and vomiting, the catamenia] and seminal discharges in ex- 
cess, are capable of producing syncope and general debility. The 
depression and faintness induced by these, although less prompt, 
are often more permanent than those from blood-letting; for such 
evacuations imply, not only reduction hi the mass of blood, but 
also an exhaustion of the vital energies in the secretions and func- 
tions concerned in producing them. 

The diseases gradually induced by these several causes of eva- 
cuation are seldom of a simple kind. General debility of the 
muscles and functions is commonly a result; but this is often 
complicated by symptoms of partial reaction, palpitation, spasms, 
noises in the head, images in the sight, pains in different parts, 
sometimes very acute, but seldom long fixed, partial paralysis, 
and a defective and disordered state of the excretions. 

71. (8.) Of all the exciting causes of disease, there are none 



TEMPERATURE. 55 

so common as temperature in extremes, or in sudden transitions; 
cold, heat, and sudden transitions from cold to hot, or hot to cold. 
Both heat and cold have different modes of operation, and cause 
disease in different ways. 

Extreme heat and extreme cold are directly destructive to life. 
Heat above 180° coagulates the albumen of the blood, and thus 
obstructs the blood-vessels, and may cause other chemical changes 
of a disorganizing nature, (§ 53:) a part that has been raised to 
this temperature, therefore, necessarily dies; it cannot live again. 
It is true that we occasionally see boiling water at 212°, boiling 
oil at 600, and ret hot iron at 1000°, produce no other effect than 
violent inflammation and blistering of a part; but that is because 
these bodies have been applied for too short a time to do more 
than violently stimulate the part, not time enough to raise it to 
the decomposing temperature; a few seconds more, and the part 
would be killed. 

Cold below 32° freezes the water of the fluids; and as it destroys 
the life of tender plants, so it kills parts of animals, whether by 
the expansion of the ice injuring the delicate organization (Sir B. 
Brodie,) or whether from the mere stoppage of the circulation, or 
other cause, is unknown. The part may be afterwards separated 
from the living parts by a vital process of inflammation and 
sloughing. 

72. A disorganizing degree of heat extensively applied acts 
like a violent mechanical injury — such as tearing off or crushing 
a limb, (§ 52.) It directly depresses all the functions: the pulse is 
very weak, frequent, and irregular; the muscular strength almost 
annihilated, and consciousness may be nearly or quite suspended. 
In this state, notwithstanding the stimulant properties of heat, and 
the inflammation which it generally excites, patients require sti- 
mulants, and they often die in a state of complete collapse, with- 
out any rallying or reaction. Extreme cold, also, if for some time 
applied to the whole body, depresses and paralyzes all its powers, 
even that of generating heat, and, therefore, of resisting cold. Sir 
Astley Cooperobserved, thatonplungingkittens into ice-cold water, 
th<' arterial blood did not become venous in the veins; andChossat 
found, in animals killed by cold, arterial blood in the left cavities 
of the heart. From a similar cause, the limbs become benumbed 
by extreme or continued cold: thus persons are drowned in cold 
weather much more speedily than in warm. With less intense 
degrees of cold, on the other hand, which do not destroy the vital 
processes, more oxygen is absorbed, more carbonic acid formed, 
and heat generated, which are the means by which animals resist 
cold. 

73. Heat which is insufficient to decompose is directly stimu- 
lant. It excites the functions of parts, and when generally applied, 



56 



EXCITING CAUSES OF DISEASE. 



induces a state of fever. Thus when a person is in a vapour bath, 
or hot air-bath, the pulse quickens, the whole surfaee becomes 
red, full, and hot; there may be throbbing and pain in the tem- 
ples, and a feeling of feverish oppression, until a sweat breaks out, 
which relieves the superficial tension and fulness, and soon re- 
duces the increased heat. Similar results may ensue from con- 
finement in overheated rooms: and if there be any tendency to 
local congestion or inflammation, particularly in the head, this 
excitement may be enough to produce it. the continuance of 
heat enervates, reduces the strength and appetite, and may excite 
a feverish state, with disorders of the liver. The oppressed 
breathing which is often felt in heated rooms may, according to 
the view of Liebig, be ascribed to the smaller amount of oxygen 
in the air rarefied by the heat; but it is probable that this is not 
the only cause. 

74. A more partial exposure of the body to heat may produce 
still more disordering effects, if the part overheated be capable of 
suffering from the excitement. Thus solar or artificial heat to 
the head may cause severe headache, apoplexy, or inflammation 
of the brain. Heat to the spine, as on sitting with the back near 
a large fire, is very apt to cause sickness and faintness, and, if 
continued, may induce convulsions. More local inflammations, 
as of the eye, ear, and skin, are frequently caused by exposure of 
the parts to heat. Gout may sometimes be excited in the feet by 
the same stimulus, and this is often attempted purposely. 

75. Cold, on the other hand, is directlv sedative. It contracts 
tissues and vessels, especially the arteries, and thus at first renders 
parts pale and shrunk. In persona of feeble circulation, after 
bathing, the fingers are sometimes quite bloodless and numb from 
this cause; the cold having quite closed up the arteries." But 
cold also retards the passage of the blood in the capillaries; the 
viscidity of the liquor sanguinis seems to be increased; globules 
stick to the sides, or move but slowly, and the part soon becomes 
purple or blue from the congestion of blood in it. This purple 
colour is chiefly seen in parts much exposed, and where the blood 
habitually enters with freedom, as the cheeks, ears, nose, and 
hands. There is also much internal congestion from the intro- 
pulsive operation of the cold— that is, the external parts being 
constricted and obstructed, blood accumulates more in internal 

* A similar effect may be seen under the microscope, on applying ice-cold 
water to the frog's web: the arteries contract to obliteration. This is contrary 
to the assertion of Poiseuille. (See my Gulstonian Lectures, Med. Gaz., July 
16, 1841, p. 639.) It must be remarked that the elementary action of cold on the 
arteries is strictly stimulant, exciting their vital property of contraction; but its 
operation on textures and organs is sedative, because it" impairs the circulation 
which supports their functions. So, too, Ave have found, that where it reaches 
the heart it paralyzes its powers, (§ 73.) 



COLD — MODES OF ACTION. 57 

parts, and the heart's force is more expended on these. This 
may in part account for the degree of stupor and ultimate insen- 
sibility into which persons exposed to extreme cold are apt to 
fall. In some such cases there has been a flow of blood from the 
nostrils or ears: the stupor has continued for hours after the heat 
and circulation have been restored; and, in fatal cases, much 
serous effusion has been found in the brain.* 

76. Hitherto we have considered the immediate operation of 
cold, (§ 73, 75.) But its indirect effects are more commonly 
known: these are, reaction, irritation, inflammation, and their 
consequences; and they will be more manifest where the cold 
has been partial, and the strength of the circulation generally not 
reduced. Thus, after a part has been exposed to severe cold, 
when restored to warmth, it becomes the seat of increased flow 
of blood, which causes redness, pain, and more heat; and various 
forms of inflammation may ensue, generally modified by the spe- 
cific effect which the previous cold has exerted on the vessels and 
nerves; varying also with the strength of the general circulation. 
Thus, as the indirect effects of cold in a part, we may have chil- 
blain, gangrenous or erysipelatous inflammation, and paralysis, 
or altered sensation. As much of the disease in these partial 
effects of cold arises from the violence of the reaction and inflam- 
mation, and this depends on the sudden return of heat and circu- 
lation in the part, it becomes an obvious indication, for frost-bitten 
limbs, to retard this return by cold applications. But Dr. Alison 
well remarks, that this precaution is not needed, where the seda- 
tive effects of cold have been more general; here warmth and 
stimulants may be used freely, for there is no fear of partial inju- 
rious reaction. 

77. We have hitherto chiefly considered the manner in which 
cold causes disorder in the parts to which it is applied; but this 
is not the most common mode in which cold excites disease. A 

i gets his feet wet, stands in a draught of cold air, or is ex- 
I to cold when insufficiently clothed; he afterwards becomes 
diseased — not in the feet, or the parts chilled, but in some inter- 
nal part. He gets a sore throat, a "cold in the head" or chest, 
an inflammation of the lungs, a rheumatism in the limbs, a loose- 
ness of the bowels, a catarrh of the bladder, or any other disease 
to which lie may be predisposed, (§ 14.) Now how does the 
external cold cause internal disease? How is the effect trans- 
ferred from externa] to internal parts? 

Dr. Alison supposes that ihe cold operates chiefly on the nerves, 
and that the sensation which it excites is conveyed also by the 
nerves to the internal organs, where its morbid effects become 

* Kellie, Ed. Med. Journal, vol. i. p. 304, quoted by Dr. Alison. 



58 EXCITING CAUSES OF DISEASE. 

manifest. But it must be objected (hat the morbific effects of 
cold are by no means proportioned to the sensation, or known 
nervous impression which it excites. A person may have his 
limbs aching and benumbed with general cold; yet internal dis- 
ease does not result. But it' he has been exerting himself, is 
perspiring, and then gets his feet wet, or is otherwise exposed to 
cold, especially partial, without continuing his exercise, although 
he may scarcely feel the cold, yet he will be pretty sure to catch 
cold, and to exhibit some one or other of its internal morbid 
effects. 

It would seem more probable, therefore, that external cold ex- 
cites internal disease by deranging the circulation, particularly 
that in the capillaries. Cold cheeks the external secretion, the 
perspiration: it constricts and obstructs the vessels of the surface 
(§75,) and must thus throw more blood inwardly, so thai internal 
congestions are produced — these internal congestions may be the 
commencement of disease. This intropulsive effeel of cold will 
take place more readily and to a greater extenl in proportion to 
the weakness or relaxed state of the capillary circulation. This 
may be weak naturally. (§ 20;) in this case there is a constant lia- 
bility to -take cold." Or it may he weak and relaxed from pre- 
vious excitement, during fatigue (§23,2 I. or during sleep. Hence 
persons are more apt to catch cold after being in a hoi room. 
after exertion, or when asleep. On the other hand, the injurious 
effect of cold is lessened or prevented by a vigorous state of the 
capillary circulation, -whether that vigour he natural, or excited 
by continued exertion, stimulating drinks, or by febrile excite- 
ment, (§ 17.) 

On this view we can understand why partial hut continued 
cold, such as from draughts of cold air, wearing damp clothes, 
standing on cold stones and the like, should be particularly in- 
jurious, even when the sensation of cold excited is not great. 
Such causes of cold, acting long on the same part, more com- 
pletely constrict its vessels, check its secretions, thus more surely 
injure the balance of the circulation, and by throwing a corre- 
sponding amount of congestion inwardly, fix' it in some part pre- 
disposed to disease, (§ 14.) 

78. When a person has thus taken cold, which he knows by 
general sensations of coldness and weak circulation, rather than 
by any feelings in the part chilled, powerful measures which 
tend to restore the balance of the circulation, such as violent ex- 
ertion, a hot or vapour bath, or stimulant drinks, may often yet 
prevent the further progress of disease. The general application 
of cold, if not long continued, is less injuriouslhan that which is 
partial, both because it disturbs less the balance of the circula- 
tion, and because also it supplies the lungs with denser air, and 



COLD — MODES OF ACTION. 59 

therefore more oxygen; and its impression on the nerves of the face 
and chest excites more energetic respiratory movements, which 
maintain the heat and the vigour of the circulation. Healthy 
persons rarely take cold when travelling on the top of a coach or 
in a perfectly open carriage, but they frequently suffer in a close 
carriage partially open. 

79. Susceptibility to the morbid effects of cold is to be dimi- 
nished by means which invigorate the capillary circulation, es- 
pecially those which promote that process of reaction by which 
cold is naturally resisted. Now nothing tends to increase this 
more than sudden artificial applications of cold, as by cold bath- 
ing or sponging, followed by friction, exercise, heat, or stimulant 
applications, which promote the reaction, (§ 16.) The great art 
in usefully applying cold with these intentions, consists in using 
the cold in such manner and degree, and having the body in such 
a state before and after the application, that the reaction or glow, 
which is the sign of vigour in the capillary circulation, shall be 
most fully produced. If, on the other hand, the cold be applied 
too long, or when the body is exhausted by fatigue, exertion or 
other cause, (§ 20,) or is naturally too weak, depressing effects of 
cold will continue, there will be little or no reaction, the sensa- 
tions of langour and chilliness show that the cold has been inju- 
rious instead of beneficial. The addition of salt to the water of 
baths gives it a stimulant property which promotes reaction, and 
a similar influence results from the force or shock with which the 
water is applied. This shock excites deep and forcible respira- 
tions through an impression on the incident nerves; and these 
are probably the efficient cause of the process of reaction which 
follows. 

The reaction which follows the judicious use of cold as a the- 
rapeutic agent, may prove serviceable, not only in resisting the 
further influence of cold, but also to remove congestions and irre- 
gularities in the circulation from other causes, and to excite in 
the capillaries and secernents new actions, which may supersede 
those of disease. It is thus that the "water cure" of Priessnitz 
chiefly operates; and although too powerful an agent to be en- 
trusted to unskilled and unscientific hands, it promises to become 
a valuable addition to the means of combating diseases, particu- 
larly of a chronic kind. 

In the preceding remarks on cold, it must be borne in mind 
that the term cold is applied relatively, not absolutely; cold is not 
a fixed temperature or range of temperature; but something 
considerably below the temperature of the body. Thus a body 
that has been warmed throughout to a heat of 98°, and kept in 
an excited state by that temperature, would suffer from a 
draught of air at 70°, which would be cold to the body, and pro- 



60 EXCITING CAUSES OF DISEASE. 

diice the physiological and pathological effects of cold. But if 
the body had not. been previously warmed, so that the tem- 
perature of most parts of the surface might not exceed 85°, or if 
although lately warmed, the energies of the body had not been 
exhausted by it, then air at 70°. would feel pleasant, and produce 
none of the effects of cold. This is one of many facts which dis- 
tinguish' vital -from 'physical properties. Physical or- chemical 
-.properties- are generally affected by fixed temperatures, inde- 
pendent of previous circumstances: but vital properties are 
variously affected, through that power of adaptation by which 
they are enabled to maintain the same function in varying ex- 
ternal circumstances. 



SECTION IV. 

II. NOXCOGXIZABLE AGEXTS. 

80. "We now proceed to notice those causes of disease, the 
existence of which is inferred only from the fact that disease pre- 
vails under certain circumstances not well explained, unless we 
assume that -such, causes" do exist, .(§ 12,) although we cannot 
prove their existence in any other- way, (§ 53.) These comprise 
the endemic, epidemic, and infectious causes of disease, 

I. EXDEMIC CAUSES. 

81. Persons living in a marshy district are often afflicted by a 
disease called ag-we,'which does not attack those inhabiting dry- 
lanes." Again, the inhabitants of certain deep valleys are often 

.affected with the- swelling in the neck, called bronchocele or 
goitre: the neighbouring mountaineers are not so affected; and 
when those from below remove their residence to the moun- 
tains, they often lose the disease. These are instances of dis- 
eases which may be said .to dwell among the residents in par- 
ticular spots; hence they are called endemic, in the people, 

(sv Sjj^tof.) 

82. In some cases, much doubt still hangs over the precise 
source of endemic influence; some supposing it to be in the 
water, others in emanations from the soil; but this doubt does 
not apply to the cause of agues, intermittent and remittent fevers, 
which have been clearly traced to effluvia from marshes, rice- 
grounds,- .&c. It has been -found that when the wind blows 
across these marshes, the disease appears chiefly in persons re- 
siding to leeward of them, and not to windward; and it has been 
abundantly proved, that when the marshes are drained the ague 



ENDEMIC CAUSES. 61 

ceases. From these and similar facts, it is concluded that the 
cause of the ague is an effluvium, miasm, malaria, or bad air; 
an aerial poison, which is supposed to be inhaled with the breath, 
and absorbed into the system. 

S3. The true nature of marsh malaria has not been determined. 
It has never been detected by chemical analysis. Professor 
Daniel conjectured that the malaria causing the destructive en- 
demic fevers of Western Africa, might be sulphuretted hydrogen 
evolved from the sea-water by the decomposing vegetable matter 
brought down by the rivers; but I am informed by Dr. D. B. Reid, 
that experiments made in the late unfortunate expedition to the 
Niger have negatived this notion. The microscope, rather than 
chemical analysis, may be expected to discover the nature of 
malaria. 

Although hitherto unknown in its nature, some knowledge of 
the general properties of marsh malaria has been obtained 
through its morbific effects. It seems to be heavier than air; for 
persons occupying a ground floor suffer more than those living in 
upper 'apartments. Water seems to absorb or destroy it; for 
persons on board ship, or on an opposite side of a lake, are not 
affected; whilst at a greater distance a favourable wind will 
convey the pernicious influence over land. A damp state of the 
air, however, favours its production; good fires in a house give 
marked protection to the inmates. It seems to be attracted by 
trees; for the vicinity of trees is doubly dangerous, whilst places 
beyond trees are more free from its effects than others at the same 
distance. 

E i. The chief points known with regard to the source of 
malaria are, thai it arises from the operation of the sun's heat on 
marshy ground, or on the banks or deltas of tideless rivers, after 
evaporation has proceeded to some extent; putrefaction of or- 
ganic matter not being an essential part of the process.* The 
virulence of the malaria, as shown in the severity of the disease 
excited, and in the number which it affects, seems to bear some 
proportion to the heat which has led to its development. Thus 
the ague of this country, the pernicious intermittent of Italy, and 
the malignant remittent of Western Africa and the West Indies, 
seem to arise from similar endemic causes, but differing in their 
virulence according to the degree of heat. A certain amount of 
moisture is, however, required; for a very dry season which 
desiccates a marsh, stops the malaria; and the deposit of the 
evening dew always favours its production, (§ 83.) Again, cx- 
of moisture checks its development, so that a very wet 

• Chisholm and Ferguson, Ed. Med. and Surg. Journal, vol. vi.; Trans. Roy. 
Soc. Etlin., vol. ix. 



62 EXCITING CAUSES OF DISEASE. 

season, as well as a very dry one, may render a marsh less un- 
healthy, (§ 83.) Extreme heat will not, however, diminish the 
malaria from the banks of rivers, since portions of these are 
never dry. 

It is not only marshy or low grounds that engender malaria, 
although these are the situations commonly most favourable for 
its production. All that seems to be requisite is the continued 
operation of the sun's heat on moisture stagnant at or near the 
surface of the ground. I know instances in which ague has 
attacked persons living on a height of mountain limestone, form- 
ing a small table land below greater heights. So also some 
swampy lands are not malarious, particularly peat bogs, which 
show a remarkable exemption from decomposition and effluvia 
of all kinds. 

85. The morbid effects of marsh miasms are several: intermit- 
tent and remittent fevers of various types are the most remarka- 
ble of these, and they particularly affect the new residents; but 
the older inhabitants suffer from diseases of the liver and spleen, 
nervous affections, rheumatisms, dropsy, and cachectic complaints, 
and are generally short-lived. 

One of the most remarkable characters in the diseases resulting 
from malaria is the periodicity of their attacks, and the diminution 
or cessation of the symptoms in the interval. 

86. There can be little doubt that there are different kinds of 
malaria besides that which causes intermittent and remittent 
fever, (§ 19, 81.) Thus yellow fever and plague are endemic 
diseases, probably arising from peculiar aerial poisons. The 
propagation and mortality of the latter, perhaps its very exist- 
ence, is very much to be ascribed to the filth and impurities of 
the towns where it prevails. There is now abundant evidence 
that drains, cesspools, and other repositories for effete and putre- 
fying organic matter, evolve exhalations which, when concen- 
trated, may generate low fevers; and when more diluted, may 
considerably impair the health of those exposed to them,* (§ 22.) 

87. Some other endemic diseases can be traced to more cog- 
nizable causes; as the Guinea worm, to drinking water containing 
its ova; the pellagra of northern Italy, and the plica of Poland, 
to neglect of cleanliness and healthy modes of living. 

II. EPIDEMIC CAUSES. 

88. There is another class of diseases, which, in their affecting 
many persons in the same place and at the same time, resemble 
the endemic, (§81.) But they differ in this respect, that they do 

* Sanatory Report of the Poor-Law Commissioners, by Mr. E. Chad wick, 1842. 



EPIDEMIC CAUSES. 63 

not regularly return at stated seasons, (§ 84,) nor are they con- 
fined to particular localities, (§ 82,) although they infest some 
more than others; but they attack a whole district, a whole coun- 
try — nay, almost a whole hemisphere — within a very short time; 
often coming on without obvious cause; prevailing for some time, 
then disappearing for an uncertain period; perhaps recurring 
within a few months, or years, or not within the memory of 
man. These are called epidemics, (j*^^,) like a blight or per- 
nicious influence blowing on the people; and therefore affecting 
a whole country at once. 

89. The cause of these diseases is supposed to be something 
in the atmosphere; because the atmosphere is the only thing com- 
mon to all the places so affected; but the nature of the cause is 
not known. It is true that some diseases, which seem to prevail 
epidemically, may be traced to the cognizable qualities, cold, 
heat, dryness, and moisture of the. air, (§ 72, et seq.) Thus dis- 
eases excited by cold, sometimes prevail, like an epidemic, in the 
winter; those by heat, in the summer; catarrh and quinsies abound 
in cold damp weather; croup and rheumatism become common 
during the prevalence of a cold east wind, in the spring; diarrhoea 
and dysentery are rife in the fruit season of the autumn. Others 
again, such as dysenteries, fevers, scurvies, &c, have in some in- 
stances obviously arisen from deficient or contaminated food, bad 
water, or some distinctly cognizable cause, (§ 60, 66.) And as 
these causes belong to the class of cognizable agents before noticed, 
(§ 51, et seq.) it is unnecessary to advert to them here. 

90. But there are diseases occurring epidemically without any 
discoverable connection with season or temperature. Thus an 
epidemic influenza may come on at any season of the year, rapidly 
spread through a country, and cease as unaccountably as it began. 
So, too, diseases that are usually excited by other causes, infec- 
tious and others — such as, typhus and scarlet fevers, measles, 
small-pox, erysipelas, &c. — sometimes prevail throughout a coun- 
try so generally, and often with such peculiar characters, that 
some influence besides their common causes must be concerned 
in their sudden increase. The nature of this influence is unknown; 
but it is called epidemic, (§88.) 

91. Lastly: various diseases, fevers, and inflammations, and 
almost all sorts of ailment, at some periods assume a remarkable 
character in common, or type, (as it is called;) for example, being 
attended with unusual weakness, or unusual excitement, or a tend- 
ency to haemorrhage. This is called an epidemic ox prevailing 
diathesis, or constitution. Thus at uncertain times, fevers, 
wherever arising, and from whatever source, are more low, ty- 
phoid, or adynamic, than usual; at the same time,exanthematous 
diseases generally partake of the same character; and even pa- 



64 EXCITING CAUSES OF DISEASE. 

tients affected with inflammations do not well bear the usual de- 
pletions. Of late years, this constitution has more or less prevailed, 
and may be contrasted with a period of twenty years ago, when 
an inflammatory diathesis existed, and blood-letting was advan- 
tageously employed even in continued fever. 

92. It has been before stated, (§ 8.').) that we are quite in the 
dark as to the nature of epidemic influences, or causes of dis- 
ease. Many conjectures have been advanced, some of them 
with much plausibility, but without any substantial support. Dr. 
Prout states that, shortly before and during the prevalence of the 
malignant cholera in this country, he noticed a small but decided 
increase in the average weight of the atmosphere, as if from the 
addition of some ponderous gas. At the same time, he remarked 
an unusual acidity in the saliva even of healthy persons, and 
such an absence of lithic acid from the urine, that he seems in- 
clined to suppose that a disposition to form oxalic acid was re- 
ferable to the same unknown cause which was then producing 
cholera, (§ 56.) 

Many analogical arguments may he adduced in favour of the 
notion that epidemic diseases are caused by animalcule tribes. 
This hypothesis has been ably advocated by Dr. Holland" and 
Dr. Henle.t Before I had seen the opinions of these authors, I 
had stated inmy lectures some arguments in favour of this notion, 
which will be given under the head of infection. The chief facts 
which countenance this view are the following: — 1. Epidemic 
discuses in the uncertain periods and places in which their visita- 
tions occur, (§ SS,) resemble those of blights, or tribes of insects, 
which are known to appear and disappear without evident cause. 
2. Proofs are accumulating of the occasional existence of parasitic 
animals and plants in living animals, and in some instances as 
causes of disease; (as in the case of worms and other entozoa, 
acari in itch, the rot-worm in sheep, the mycodermatous vegeta- 
tions in porrigo,J confervas in impetigo, aphthae, &c.) 3. The 
history and symptoms of some epidemic diseases, such as cholera 
and influenza, are not inconsistent with the hypothesis that they 
are caused by the sudden development of animalcules from ova 
in the blood. Put there is a total want of direct observation in 
support of the hypothesis; and, perhaps, it may be objected against 
it, that the seasons at which epidemics sometimes appear (as cho- 
lera in winter) are not always those most favourable to the de- 
velopment of animalcule life.§ 

* Medical Notes and Reflections, 1840, p. 597. 
f Pathological Researches, British and Foreign Medical Review, April, 1840. 
t Gruby, Comptes Rendus, t. xiii. Bennett, Trans. Royal Soc. Edin., 1842. 
§ The prevalence of the south-east wind was observed to be particularly fa- 
vourable to the increase of both cholera and influenza; and I cannot but think 



INFECTION KINDS.. 65 



III. INFECTIOUS CAUSES. 



93. The terms infection and contagion are applied to the 
production of a disease by a morbid matter proceeding from the 
body of another person who is, or has been, the subject of the 
same disease. The proofs that disease is thus propagated from 
one individual to another are, first, the general one, that those 
who have intercourse with the sick are affected in much greater 
numbers than those who have not, (§ 12;) and, secondly, the 
direct and individual proof, of infecting a healthy person with 
matter taken from a person in disease. This, although available 
only in some modes of infection, may be considered as a proof of 
the fact of contagion in general — that is, of disease propagating 
its kind. 

94. I have just alluded, (§ 93,) to differences in modes of in* 
fection: they may be further enumerated as follows: — 

(1.) Infection through wounds, or an abraded surface; as in 
hydrophobia, the morbid matter being contained in the saliva, or 
guttural mucus of the rabid animal; and in cow-pox, the matter 
being contained in the specific vesicle, and acting on a puncture 
or abraded surface. 

95. (2.) Infection by contact, different parts of the body being 
susceptible in different diseases; as the urethra and conjunctiva 
in gonorrhoea, the vicinity of the external openings of the passages 
in syphilis, the skin in scabies, the scalp in porrigo — the morbid 
matter generally proceeding from similar parts. 

96. (3.) Infection by exhalation from the breath, perspiration, 
or other secretion, conveyed tlirough the air to the mouth and 
;iir-]>assages; as in the case of measles, scarlatina, hooping-cough, 
typhus, and other infectious fevers. 

97. Some diseases may be propagated in several of these modes; 
small-pox, for instance, may be communicated by punctures in 
the skin, (§ 94,) by inoculation — application to the eye, (§ 95,) — 
and by diffusion through the air, (§ 96:) and probably the same 
might be effected with other febrile poisons, if their precise source 
in the body were as clear as it is in small-pox. These different 
modes of infection merely show that the infecting matter can exist 
suspended in the air, as well as in a fluid or solid state; and ac- 
cording to tins*: conditions, it may get access to the system by 
different avenues. 

that this had some connection with the general tendency exhibited by the former 
to spread chiefly from east to west. Has the morbific property of this wind aught 
to do with the haziness of the air when it prevails — a haziness seen in the coun- 
try remote from smoke, and quite distinct from fogl What is this haze? In the 
west of England, a hazy day in spring is called a blight. 
6* 



66 EXCITING CAUSES OF DISEASE. 

98. Many of those who are skeptical as to the reality of infect- 
ion, aim their objections only against aerial infection, and do not 
question the other modes. But the difficult problem is, not that 
the infectious matter may be diffused through the air — our smell 
informs us that animal effluvia are constantly so diffused — but 
the difficulty lies in the fact of infection by any mode; that is, that 
disease should propagate its kind. There are only two parallel 
cases in nature, in which analogous properties are possessed by 
matter. One is the case of what is called septic matter, leaven, 
or ferment; a little of which introduced into organized matter 
will promote changes and decompositions — "A little leaven lea- 
veneth the whole lump." This property is supposed, by Liebig 
and other chemists, to be chemical, operating in the manner of 
heat, by altering the molecular relations of compound matter; but 
by Cagniard De la Tour and other microscopic observers, it. is 
stated, that fermentation is caused by the production and growth 
of living molecules or vegetables, and thai it spreads by the pro- 
pagating power of these. This would transfer this case, that of 
leaven or ferment, into the next category, (§ 99.) 

99. The other case analogous to propagation of disease by 
infection, is the vital power of generation; in this case, as in that 
of contagion, matter propagates its own kind in the animal and 
in the vegetable world. Does the matter of contagion consist of 
animal ova or vegetable seeds? Are infectious diseases \\w results 
of the invasions and operations of living parasites disturbing in 
sundry ways the functions and structures of the body, each after 
its own kind, until the vital powers either fail, or succeed in dis- 
pelling the invading tribes from the system? (§ 16.) Such an 
opinion has hen many times proposed, and is, in a degree, implied 
in the term incubation, (sitting on eggsto hatch them,) commonly 
applied to the period between the reception of the infection and 
the first appearance of the symptoms. In support of this notion 
may be adduced the case of itch, which certainly infects by its 
cause, the itch-mite, and spreads by this animal's propagation; 
and the case of porrigo, or favus, which probably depends on a 
parasitic vegetable, and infects through the seeds or sporules of 
this vegetable.* But these, it may be objected, are instances of 
mere local disease, and by no means like the cases of infectious 
fevers and syphilis, which affect the whole system. 

The case of small-pox and cow-pox might seem to be more in- 
telligible, because the infectious matter is found to reside in the 
incipient pustule; but this throws no further light on the subject; 
for the lymph of these vesicles has not been hitherto found to con- 

* Schonlein, Muller's Archiv., 1839, p. 82. Gruby, Gazette Medicale, Juillet 
17,1841. 



INFECTION NATURE — PECULIARITIES. 67 

tain any thing which can account for its disseminating property. 
The microscope should solve this problem, by detecting the germs 
and growths of these infecting organisms, if such exist. Until this 
be accomplished, the nature of contagion must remain a matter 
of speculation. 

100. The parasitic nature of infectious matters may receive 
some support from the little that is known of their general pro- 
perties, which further deserve to be mentioned on account of 
their practical importance. Infectious matter is destroyed by a 
temperature above 120° Fahr., and by strong chemical agents, 
especially chlorine: its activity is impaired by cold; and in case 
of aerial infection, by intense cold and free ventilation it is ren- 
dered harmless. Hence infectious diseases usually cease when 
hard frost sets in. On the other hand, warmth, closeness, and 
filth, increase the virulence of contagion, and become, as it were, 
a hotbed of pestilence. Nothing tends to promote the spread of 
an infectious disease more than crowding together several who 
are suffering under it. Each one is a separate source of' con- 
tagion; and if these sources are multiplied in an apartment, the 
air will be contaminated in proportion. I believe this to be the 
chief reason why, in fever hospitals and fever wards, medical 
attendants and nurses escape infection much more rarely than in 
hospitals where the fever patients are widely distributed among 
other patients. 

It may be useful again to point out the peculiarities which dis- 
tinguish infections from endemic and epidemic diseases; for these 
peculiarities are proofs of the reality of infection as a separate 
cause of disease. 

101. Infectious diseases first attack individuals in any locality, 
then gradually spread in the vicinity of those diseased, or in the 
direction where there is most human intercourse. Where care 
is taken, early and completely to separate the diseased from the 
healthy, disease does not appear among the latter. 

102. Endemic diseases may simultaneously attack many indi- 
viduals in certain localities only, (§ 81); they do not spread be- 
yond these localities; no separation of the sick from the healthy 
will save the latter, but removing the healthy to another spot 
gives them security. 

10.3. Epidemic diseases simultaneously attack numbers in any 
locality, (§ 88:) they increase not peculiarly in the vicinity of 
l In isc first affected, nor in proportion to intercourse witli them, 
but rather in proportion to the prevalence of other causes that 
may be called predisposing or determining causes, (§ 19.) 

104. It must not be forgotten that some diseases are suspected 
to originate and spread in two or even all of these modes. Per- 



68 EXCITING CAUSES OF DISEASE. 

haps this may be said of typhus fever, plague, cholera, and dys- 
entery. It has been already mentioned that infectious diseases, 
as small-pox, scarlatina, and measles, are occasionally increased 
and modified by epidemic influences, (§ 90, 91;) and the same 
thing may be said of some endemic maladies. So also the aggra- 
vation of contagious and epidemic complaints by endemic im- 
purities, (§ 85,) makes it plain that all the class of causes may 
operate conjointly. It is under such circumstances of aggrava- 
tion, or under those of strongly prevailing predispositions, as from 
famine, (§ 21,) fatigue, (§ 23,) confinement, (§ 22,) or mental de- 
pression, (§ 27,) that this class of diseases become. so destructive 
as to be called pestilential or malignant. 

105. The direct operation of most of this class of causes is 
depressing, and where they are strongest and prevail most, the 
resulting disease is one of depression, adynamia, asthenia, or 
prostration of the vital powers. These causes are therefore com- 
monly designated specific poisons. But there is the antagonist 
principle of vital resistance in the system, (§ 16,) which leads to 
various processes of reaction, which may be exhibited in different 
degrees, according to the relative strengths of the poison and of 
this resisting power; and likewise often according to various cog- 
nizable agents which simultaneously act as predisposing, deter- 
mining, or co-operating causes. For instance, in warm weather 
the poisonous influences are generally strong, (§ 84, 100,) and the 
bodily powers weak, (§ 24;) the resulting disease is one of more 
complete adynamia. In moderately cold weather, on the other 
hand, the specific poison is less active, and the system is ready to 
react, not only against it, but against the cold with which it may 
be combined; this causes a more inllammatory type in the conse- 
quent disease, (§ 76, 77.) 



CHAPTER II 



PATHOLOGY (PROPER)— THE NATURE AND 
CONSTITUTION OF DISEASE. 

106. Disease is a change from the natural condition of the 
function or structure of the body, (§ 6, et seq.;) but the change 
is generally more or less compound, involving several elementary 
functions or structures; and it is obvious that we cannot obtain 
an accurate knowledge of the nature of disease until we have 
ascertained that of its component parts. As the anatomist and 
physiologist examine structure and functions by separating or 
analyzing them into their constituent parts, before he contem- 
plates them in combination, so should the pathologist study these 
constituent parts, or elements, in disease, before he can under- 
stand their combinations.* 

The chemist, in the examination of his subjects, finds that there 
are some principles or elements that cannot be analyzed or di- 
vided further; these he calls ultimate or primary elements: others, 
again, are simple compounds, which may be analyzed; but they 
occur so constantly, and act so singly in compounding and giving 
properties to complex matter, that they are called proximate 
principles or secondary elements. A parallel case might be 
shown of |>liysie;il science. 

107. So ii should he with physiology and pathology.! There 
are the healthy and diseased primary or ultimate elements of 
structure — muscular fibre, nervous matter, vascular fibre, and 

ect of this precept has greatly retarded the advancement, nay, even 
il"- formation, of pathological science. Men have begun with the very complex 
of inflammation and/ewer, before they have made themselves acquainted 
with the elementary properties of textures, or even of vessels. The result has 
hal the most profound reasoning and ingenious speculations have been 
Wasted on nonentities, such as spasm of the extreme vessels, increased action of 
the capillaries, &c; and even observation has been confused by the complexity 
of the subjeci brought under it 

; I i pursued this .synthetic mode of teaching general pathology, in my 

lectures, during the last three years. I am nol aware that it has been Cully used 
by any other writer, although several (as Andral and Carswell) have partially 
lized it in their divisions of the objects of morbid anatomy; and mj friend, 
Dr. Symond . has adverted to the parallel of chemistry, and actually employed 
the term, proximate principle ofdj ;a e, in the same sense in which I use it. — 
Library of Practical mediane, vol. i., Pathological Introduction* 



70 ULTIMATE AND PROXIMATE ELEMENTS OF DISEASE. 

the elementary tissues of membranes, glands, skin, and other 
parts; and there are primary elements, healthy and diseased, of 
function of these same structures — irritability, tonicity, nervous 
properties, to which may be added, because at present we can- 
not analyze it, the power of secretion and nutrition; and lastly, 
the constituents of the blood. And there are the secondary or 
proximate elements of disease, composed of the preceding pri- 
mary elements, but still simple in comparison with the complex 
conditions of disease which they combine to produce. 

108. The following are the chief of these proximate elements: 
the blood-vessels and their different conditions, anosmia, plethora, 
congestion, determination of blood, and inflammation; the nervous 
system, with its different functions, sensation, volition, reflected 
excitement, sympathy, and irritation; the secreting organs and 
membranes, with their relations to the vessels, the nerves, and to 
the purposes which the secretions serve in the animal economy: 
lastly, (and here we must drop physiology, for the subject is pe- 
culiar to pathology,) the elements of structural diseases, new 
formations, and parasitic creatures. 

These, with a few more of less importance, constitute the 
secondary or proximate elements of physiology and pathology: 
we have to consider them in relation to pathology only. 

109. These primary and secondary elements of disease are 
the especial subjects of general pathology. By the study of them 
we become acquainted with the mat( rials of disease, and their 
relations to each other; we Learn how special diseases arise, and 
of what they consist; how they produce their phenomena and 
effects, how they are to be known, distinguished, and classified. 
Out of such a knowledge, where it is correct, sufficient, and com- 
bined with an ample acquaintance with the properties of reme- 
dial agents, arises the rational method of relieving, curing, and 
preventing disease, the great ends of the art of medicine. 

I readily admit that our knowledge of these elements, these 
principles in pathology, is as yet too limited to be entitled to rank 
as a science; but I think that the attempt to describe and illus- 
trate them will be useful, not only by making available all that 
is known on the subject, but also by showing what is not known, 
and needs investigation: thus suggesting fit subjects for further 
research. / 



FUNCTIONAL OR DYNAMIC DISEASES. 
PRIMARY ELEMENTS. 



SECTION I. 

PROPERTIES OF THE MOVING FIBRE. IRRITABILITY. 

110. Irritability, irritable contractility, or the property of 
contracting on the application of a stimulus or exciting agent, is 
the distinctive property of muscular fibre. Although some phy- 
siologists maintain that this property is derived from some part 
of the nervous system, they have not produced any conclusive 
proof; it is therefore more philosophical to retain the Hallerian 
view of intrinsic irritability.* 

111. It may become excessive, so that the contraction is too 
violent for the welfare of the part or of the system. This con- 
stitutes spasm or convulsion. The excess of irritability may be 
manifest in three ways: — 1. By an excessive strength and degree; 
2. By an inordinate quickness or promptitude; 3. By the unusual 
duration of the contractions. 

112. (1.) Excessive strength of muscular contraction is exem- 
plified in the violent action of the heart during exertion or other 
excitement; and in the extraordinary muscular power of a deli- 
rious patient, who can master persons naturally stronger than 
himself. This exaltation of the natural property may depend on 
the excessive stimulus, as of blood in the heart, or of nervous ex- 
citement in the case of the delirious patient; or it may arise from 
the muscles being over-fed with blood. 

113. (2.) Inordinate readiness or quickness of contraction con- 
stitutes mobility of muscle, a slight stimulus causing it to con- 

* Dr. M. Hall ascribes irritability to the spinal marrow; but he mentions an 
experiment which is conclusive against this view: — "During the half lethargic 
condition of the frog in winter, the entire cerebrum and spinal marrow may be 
removed, by slow degrees, at considerable intervals; the circulation is never- 
theless good." — Gulstonian Lectures, 1842, p. 60. The irritability of the heart, 
therefore, is unimpaired. The late experiments of Dr. John Keiil, on muscular 
irritability, are strongly in support of the Hallerian doctrine. 



72 ULTIMATE ELEMENTS OP DISEASE. 

tract. This often coexists with want of power or completeness 
in the contractions. It is exemplified in the irritable heart, which, 
although acting very frequently, does not expel its contents so 
vigorously as in health. It is seen in the quick nervous move- 
ments of irritable persons, who are at the same time weak. The 
bowels show it in that irritable looseness formerly called lientery, 
in which food is quickly passed little altered; and it is instanced in 
the irritable bladder, which will not hold even an ounce of urine. 
The pathological cause of this kind of inordinate irritability is 
either an undue flow of blood to the muscle, which exalts its 
natural property, or a predominance of irregular nervous in- 
fluence, which unduly excites this property: thus it is often ex- 
cited by irritations of the motor nerves, or of their columns or 
fibres. But the most remarkable examples are given in the 
extreme case of convulsions or clonic spasms — that is, sudden 
contraction, alternating with relaxation, as seen in chorea, epi- 
lepsy, and convulsive hysteria, where it affects the voluntary 
muscles; and in the palpitating heart, which beats irregularly, 
and out of rhythm. 

114. (3.) An unusual duration of muscular contraction consti- 
tutes tonic spasm or cramp, in which the contraction is strong, 
and not alternated, as usual, with relaxation. Such spasms are 
not unfrequently felt in the calves of the legs; and the different 
muscular canals, the gullet, stomach, the intestines, and the glot- 
tis, occasionally present this state of continued contraction. In 
most of these cases, it is accompanied by pain more or less severe, 
and may lead to serious obstruction to the function of the organ. 
When iii a more moderate degree affecting the voluntary mus- 
cles generally, it constitutes catalepsy, in which, from the muscles 
remaining contracted, the limbs will retain whatsoever attitude 
they are placed in, until the spasm is over. But the extreme 
example is tetanus, in which the spasms are so violent and so 
enduring, that they may be said to squeeze the patient to death. 
The pathological cause may be, as in other modifications of irri- 
tability, either an irregular supply of blood to the part, or irrita- 
tion, direct or indirect, of the motor nerves by which the muscles 
are excited. 

115. Remedial measures. — These must depend on the cause 
of the excessive irritability. Where this is increased flow of blood 
to the part, blood-letting, derivants, sedatives, and other remedies 
for determination of blood, may be proper. Where the cause 
is nervous irritation, narcotics are the most effectual; and some 
of these, from their peculiar efficacy in allaying spasm, are called 
antispasmodics. The most powerful of these are stramonium, 
belladonna, sulphuric aether, opium, and Indian hemp. Where 
irritability is combined with weakness, tonics are often service- 
able, especially the metallic tonics, and bark. 



DISEASED IRRITABILITY. 73 

116. Muscular contractility may be defective chiefly in two 
modes. 1. In force, (§ 112;) as in the weakness of voluntary 
muscles, during severe illness, after fatigue, (§ 68;) or under the 
influence of a depressing poison or shock, (§ 55;) and in the 
weakness of the heart under similar circumstances, and in faint- 
ness, or in the sinking which precedes death. This weakness is 
caused by the exhaustion of previous exertion, or by want of a 
due supply of blood, which is necessary to maintain all functions; 
or it may proceed from an influence positively depressing or 
destroying the muscular power, as in the case of sedative poi- 
sons, as tobacco, sulphuretted hydrogen, &c, and probably con- 
cussion and other violent injuries to the organization. The ex- 
treme effect of these agents is to cause paralysis, or complete loss 
of irritability, which, affecting the heart, constitutes death by syn- 
cope. Muscles sometimes lose their irritability by more gradual 
causes, such as rheumatic inflammation, the action of lead, &c. 
Various muscles are reduced in power by over-excitement or ex- 
ertion: this is exemplified in the paralysis of the sphincter after 
over-distension of the bladder, torpor of the bowels after the ope- 
ration of an active purgative, &c. 

117. (2.) Muscular irritability may be deficient in readiness to 
contract, (§ 113,) as in the sluggish movements of a person 
whose irritability has been lowered by opium; and in the slow 
pulse caused by digitalis, and by some cerebral affections; and in 
some cases by blood-letting or low diet. It is by no means 
deal why the same agents should lower in some cases the 
strength, and in others the promptitude in contraction; and in 
many Other respects, the laws of irritability recmire further inves- 
tigation. 

l I ^ . Although it has never been proved that muscular irritabi- 
lity is derived from the nervous system, yet the illustrations al- 
ready given plainly point out that it is much under its influence. 
The nerves are the proper medium by which the voluntary mus- 
cles are made to act, and through the nerves the motions of the 
Involuntary muscles are influenced, as instanced in the operation 
dI mental emotion on the action of the heart, (§ 69.) Hence dis- 
easesof muscular action generally rank with nervous diseases. 
Thus disease of the brain may cause a cessation of muscular 
million by suspending volition; and disease of the spinal marrow 
or nerves ni;iy do so by intercepting the influence of the will: in 
either case, muscular motion ceases, not from disease in itself, but 
for want of its proper stimulus, the will. In fact, under these 
circumstances, muscular irritability sometimes accumulates, (§ 
ill, and is brought into action, by slight impressions reflected 
from the spiiwil marrow. Thus, in complete paraplegia, or loss 
of motion of the lower half of the body, convulsive movements 
7 



74 ULTIMATE ELEMENTS OF DISEASE. 

may be excited in the lower extremities by tickling the soles of 
the feet: in other cases of paralysis, they may be produced by 
electricity. 

119. Remedial measures. — As usual, these will vary with the 
cause of the defective irritability; where it proceeds from exhaus- 
tion, repose is the obvious indication. But even here, in extreme 
cases, and more particularly in those in the second head, (§ 117,) 
it ma y be necessary at once to excite the defective irritability by 
stimulants, especially those of the more diffusible kind, as ammo- 
nia, brandy, and other spirits and essential oils; whilst the feeble 
circulation may be aided by heat and frictions. The large quan- 
tity of stimulants borne by patients whose irritability is reduced 
by accident or disease, is a remarkable feature in their history. 
A person faint from great loss of blood, (§ 71,) a crushed limb, 
(§ 55,) or a sedative poison, will bear four or five times more 
brandy than would be sufficient to intoxicate him under other 
circumstances. Electricity and the dash of cold water should be 
mentioned among temporary means of exciting detective irrita- 
bility. Strychnia and cantharides are reputed to restore power 
to paralyzed muscles. 



SECTION II. 

TONICITY. 

120. Tonicity, or tone, is a property possessed by all muscular 
structures, and by sonic which are hardly accounted muscular. 
It is a tendency to slow, moderate contraction, not essentially ter- 
minating in relaxation: hut it keeps the parts in which it resides 
in a certain degree of tension. This tone keeps muscles and 
limbs in their places when at rest, and out of their places when 
dislocated: if one set of muscles is paralyzed, the tone of their 
antagonists draws the parts in an opposite direction, as we see in 
paralysis of the portio dura on one side of the face. A similar 
property is possessed by the intestinal tube, the urinary bladder, 
the air-tubes, and the middle coat of the arteries, and gives them 
a constant tendency to contract on their contents. In these, but 
particularly in the arteries, it performs an important part, both in 
health and in disease. By this the arteries contract, when they 
cease to receive blood from the heart, and thus are found empty 
after death. It adapts them to different degrees of fulness, yet 
maintains a certain tension favourable to equality in the motion 
of the blood. 

It has been asserted, that tonicity is quite distinct from irrita- 
bility; and although irritable fibres possess tone, tonic textures 



EXCESS OF TONICITY. 75 

are not irritable. This is not true with regard to the arteries; for 
I have many times distinctly seen them slowly contract, and re- 
main contracted, at a point to which an irritant, mechanical, che- 
mical, or electric, has been applied. The late discovery, by 
Henle, of a structure distinctly muscular in arteries, confirms this 
observation. I have proved, in like manner, the irritability of 
the air-tubes, which move more readily under a stimulus than 
the arteries; whilst that of the intestines is still higher in degree, 
but still inferior to that of the oesophagus and voluntary muscles, 
the contractions of which, on the application of a stimulus, are 
abrupt, and immediately followed by relaxation. So far, then, it 
appears, that tonicity is influenced by the same agents which ex- 
cite irritability; but another agent, temperature, seems to affect 
them differently, (§ 74, 75.) Cold increases tonicity and impairs 
irritability, whilst heat diminishes tonicity and increases irrita- 
bility. Under the influence of cold, arteries shrink in size very 
remarkably;* and the muscles and other textures present a firm- 
ness and contraction which impede the quickness of motion 
characterizing the highest degrees of irritability. Under the in- 
fluence of heat, on the other hand, although muscles are relaxed, 
they are more irritable, and the pulsations of the heart are more 
frequent. 

Cold and heat, therefore, become the best tests for tonicity; and 
by their means we find this property to be possessed by textures 
which have never been proved to be irritable; I mean, the veins 
and the cutis, which contract with cold, and become relaxed with 
heat. 

Now this property, tonicity, is a very important one in the ani- 
mal economy, its natural condition being very necessary for the 
preservation of health, and its modifications being concerned in 
causing and constituting disease. Practical men have long ad- 
mitted the existence of something of this kind, without defining 
or localizing it; and the terms tone and atony, bracing and relax- 
ation, tonic and relaxing remedies, become quite appropriate in 
connection with this property. Let us notice some of the charac- 
ters of its excess and defect. 

121. Where there is an excess of tonicity, the muscles are so 
firm that there is scarcely room for free motion; the pulse is 
strong, tense, and often slow, yet there is scarcely any interval 

* This fact must be familiar to every one who has noticed the difference of 
the pulse when a limb is cold and when it is warm. But I have seen it more 
forcibly illustrated by experiment. On plunging into cold water the aorta of an 
ass just dead, it contracted so closely as to obliterate its cavity; and it required 
force to pass the little finger into it. The crimping of the flesh offish is 
referable to the same principle. 



76 ULTIMATE ELEMENTS OF DISEASE. 

between the heart's beat and the radial pulse. The capillary cir- 
culation is active, and the extremities warm; but owing to the 
tense state of the vessels and of the skin, the secreting organs do 
not act freely, the urine is high coloured, the bowels are disposed 
to be costive, and the skin to be dry and hot. This is a condition 
leading to sthenic plethora or local congestion, active haemorrhage 
or inflammation, apoplexy and gout; but there is less than usual 
proclivity to infectious diseases and others of a depressing cha- 
racter. 

122. Remedial measures. — In such a state blood-letting is but 
a temporary remedy. As long as the tonic fibres are too much 
braced, the secretions will be defective, and the vessels will fill 
again and renew the danger. The measures best suited for this 
state of excessive tone are those tending to relax the tonic fibre, 
and increase the secretions, such as warm bathing, exercise, sudo- 
rifics, aperients, and diuretics, With moderate diet. It is probable 
that some remedies, such as antimony, reduce directly the tone 
of the vascular fibre, acting as relaxants. We shall have to advert 
to this subject again under the head of inflammatory fever, of 
which the element, excessive tone of the vascular system, is a 
chief constituent. 

123. Where tonicity is defective, the muscles are flabby and 
incapable of continued exertion, but sometimes are too irritable, 
with the tremulousness of debility, (§ 113.) The heart likewise is 
irritable, and often exhausts its strength in palpitation; the pulse 
is soft and unsteady; it may be full when slow, but it is without 
strength, and easily accelerated. Its most distinctive character, 
however, is its retardation, increasing the interval between the 
heart's beat and distant pulses; so that the radial pulse is often 
felt after the second sound of the heart is heard; (§ 121:) the tubes 
being less tense, the pulsewave is slower than usual, (§ 120.) So 
too the loose relaxed state of the vessels renders the circulation in 
distant parts weak, so that the extremities are cold, whilst the 
head may be congested. Sudden exertion or change of posture 
may disturb the circulation and cause faintness or giddiness. 
Want of tone also in the stomach and intestines causes indiges- 
tion and costiveness, and permits them to become distended with 
wind and accumulating faeces. The secreting organs, irregularly 
supplied with blood, are also liable to disorder, being either scanty, 
depraved, or profuse and wateiy. 

It is quite obvious that a person in such a condition must be 
prone to various diseases. He has no resisting power (§ 16) 
against malaria, infection, or other depressing agents. If he is 
exposed to cold, the blood is readily driven through the weak 
vessels into the interior, (§ 77,) where it causes congestion or in- 



DISEASED SENSIBILITY GENERAL. 77 

flammation. The weak intestines, have no power to expel offend- 
ing matter from them, (§57.) Thus the system in a state of atony- 
is open to the action of many exciting causes of disease; besides 
being itself in many respects on the very verge of disease. 

124. Remedial measures. — The proper remedies in such a 
condition are tonics, or those agents that tend to increase the tone 
of the system, (§ 120,) particularly of its muscular and vascular 
parts. We have already stated that cold has this effect in a 
marked degree, (§ 79;) and in truth, cold, properly applied, is one 
of the best tonics which we possess. For this purpose its appli- 
cation should be sudden, and too brief to cause depression or any 
of its morbid effects. The shower-bath and plunge-bath are the 
most effectual forms; and free sponging, with cold salt water, is 
applicable even to weak subjects. A pure bracing air and much 
exposure to it have also useful tonic effects. There are many 
medicinal tonics, the most effectual of which are bark and its pre- 
parations, medicines containing iron, and the mineral acids. Gene- 
rous living may be considered a part of a tonic plan, in so far as 
it tends to supply blood, which is the pabulum of tonicity as well 
as of other vital properties. 



SECTION III. 

PROPERTIES OP THE NERVES. SENSIBILITY. 

125. Certain parts of the nervous system being known to be 
the instruments of sensation, we have no difficulty in tracing dis- 
eased sensibility to this system: and as this system consists of a 
medullary centre, and of nerves converging from various parts to 
it, bo we find that alterations in the property may depend either 
"ii disease of the centre, causing disorder of general sensibility, 
or on disease of one or more of the nerves, causing disorder of 
local sensibility. These we shall now notice. 

DISEASES OP GENERAL SENSIBILITY. 

These may consist in — 1, excess; 2, defect; 3, perversion. 

126. (1.) Excessive sensibility is more or less present when 
the nervous centres are excited in the early stage of their inflam- 
mation or of determination of blood to the head; where there is 
intolerance of light, noise, and motion. A similar condition exists 
in hydrophobia and tetanus, from mere excitement, without in- 
flammation. But short of these, sensibility is excessive in some 
persons, either congenitally, (§ 44,) or as a consequence of disease, 
(§ 31, 9 !.) Such persons arc commonly called nervous; they are 

7* 



78 ULTIMATE ELEMENTS OF DISEASE. 

worried with trifles; startled at shadows; distracted by noise or 
bustle; never free from some ache or pain; for almost every feel- 
ing is suffering; and what in others would be slight pain, in these 
amounts to agony. Hence they are perpetual invalids, quite unfit 
for the rugged path of life, over which they, as it were, walk bare- 
footed and thin-skinned. If real disease attack them, its nervous 
symptoms are so much exaggerated, that a medical attendant is 
apt to fall into the error of either ascribing all to .« the nerves," or 
of measuring the disease by the severity of the symptoms. This 
over sensibility is generally conjoined with excess of irritability, 
and want of tone, (§113, 123.) Other nervous functions, such as 
sympathy and reflex action, are also often augmented or in dis- 
order. The symptoms connected with sensation most frequently 
present are neuralgic pains of various parts, excessive sensibility 
of the surface, headache, pain in the back, and spinal tenderness. 

127. The pathological cause of increased general sensibility is 
probably a slighter degree of the same cause which induces it in 
the early stage of encephalitis, an undue supply of blood to the 
posterior columns of the spinal marrow, the corpora restiformia, 
and the parts of the cerebral mass concerned in sensation. This 
local determination of blood may result from original development; 
but it may also be a consequence of inflammatory affections of 
the encephalon, of irregularities in the menstrual functions, or of 
the reaction ensuing after great losses of blood, all of which are 
known to be sometimes the precursors of morbid sensibility. On 
a future occasion, in connection with the subject of irregular dis- 
tribution of blood, we shall endeavour to point out why great 
losses of blood and other causes of sudden weakness are some- 
times followed by excessive sensibility. The over refinements 
and luxurious habits of the upper classes, with more excitement 
for the mind than for the body, and for the feelings than for the 
understanding, are well calculated to foster morbid sensibility, 
(§69.) 

128. Remedial measitres. — The medicines most in opposition 
to this element of disease are narcotics or anodynes, such as 
opium, henbane, hemlock, Indian hemp, &c, administered inter- 
nally. These diminish nervous sensibility; and in proportion as 
this is exalted, (§ 126,) the system will bear larger doses. But 
where the increased sensibility depends on inflammation or vas- 
cular excitement of the nervous centres, (§ 127,) the proper treat- 
ment will obviously be that to be hereafter described as antiphlo- 
gistic. Again: where the excessive sensibility arises from nervous 
excitement and irregular circulation, with general weakness, 
(§ 116,) and atony, (§ 123,) (by no means an uncommon combi- 
nation,) tonics, (§ 124,) and stimulants, (§11 9,) as well as narcotics, 
are the proper remedies. Weakness and slow transmission of the 



DISEASED SENSIBILITY GENERAL. 79 

arterial pulse, (§123,) and absence of flush or heat of skin, are the 
chief symptoms of such a condition. In these and other common 
cases of morbid sensibility, country air and exercise, plain food 
for both mind and body, early hours, and an avoidance of all 
enervating habits, are often more conducive to the cure than any 
medicines. 

129. (2.) Defective general sensibility in its extreme degree is 
exemplified in coma from the circulation in the sensitive centre 
of the nervous system being impeded in consequence of pressure, 
congestion, or other obstruction, (§ 54,) or of narcotic influence. 
Thus a person in a fit of apoplexy, or poisoned by opium, has 
lost all feeling, as well as voluntary motion. When the blood 
becomes impure by retention of excrementitious matter, as in 
suppression of urine, a like stupor occurs, (§70.) ' Very rarely 
anaesthesia exists — that is, loss of sensation, without loss of mo- 
tion. But short of these degrees, there are some who congeni- 
tally, (§ 44,) from disease, (§ 31, 34,) or from age, (§ 51,) are defi- 
cient in sensibility — feel less than other folk. All their feelings 
are obtuse and their actions slow; they have no intense suffering 
or pleasure. Such persons have also little irritability, but much 
tone of fibre, and are remarkable for their immunity from many 
diseases. But they are the more liable to others, such as fulness 
of blood, apoplexy, gout, costiveness, and the various evils which 
these may bring. They contrast well with the over-sensitive in 
this, that disease when it occurs may advance far and become 
dangerous before it is felt; and may imperceptibly increase until 
it is past removal, or until sudden death ensues. 

L30. Remedial measures. — When obtuseness of feeling arises 
from fulness, obstruction or pressure of blood in the nervous 
centres, the treatment will consist in attempts to remove these 
by depletion, derivation, and other means to be mentioned under 
the head of disordered circulation. Where there is no actual 
disease present, but merely a torpor of the sensitive function, 
menial excitements and bodily exertion, cold bathing and friction, 
are the best means of preventing a gradual descent into a state of 
lethargy. It is doubtful whether we have any medicine capable 
of directly increasing sensibility. Strong tea and coffee perhaps 
have the best claim to such a property. What effect would arise 
from electrifying the spine and occiput? Stupor and impaired 
sensibility may arise in a state of anaemia, as in cerebral syncope, 
and in children or females who have lost much blood; this is from 
stagnation of the blood in the brain. I fader such circumstances, 
the pallor of the skin and weakness of pulse would indicate 
stimulants as the best means of restoring sensibility. 



80 ULTIMATE ELEMENTS OF DISEASE. 

131. (3.) Perverted general sensibility is often manifested by 
those in whom there is also increased sensibility, (§ 126,) but its 
character is in the peculiarity of the sensations which are experi- 
enced. Thus sensations of tingling, prickly heat, trickling cold, 
in various parts; feelings of a lump in the throat, a hot ball in 
the side, a fluttering at the stomach, and illusions of the special 
senses, may severally and variously affect persons whose sensi- 
bility is modified more in kind than in degree. Such persons 
may also have a depraved appetite, craving for sour things, cin- 
ders, mortar, and all manner of filth. These symptoms generally 
occur in females, often in connection with irregular menstruation, 
therefore they are called hysterical; but their pathological cause 
must be sought in the nervous system, the functions of which, 
probably from irregular supply or bad quality of the blood which 
supports them become disordered. The remedial measures in- 
dicated for this condition are therefore those calculated to remove 
its cause: chalybeates and other tonics, with pure air, nourishing 
food, and other means which improve the quality, and equalize 
the distribution of the blood. Narcotics and sedatives may be 
useful as temporary palliatives. In rare cases, the general sensi- 
bility is perverted by structural change in the nervous centres, 
such as softening of the cerebral structure. 

DISEASES OF SENSIBILITY OF PARTS. 

132. The feeling of a part may be excessive, defective, ox per- 
verted. This may be illustrated by experiment. By irritating 
or striking a nerve, pain is produced in the part to which it is 
distributed, and the sensibility of the part remains exalted — that 
is, it feels tender afterwards. By pressing on the nerve, a new 
and perverted sensation of tingling and pricking, with numbness, 
is caused. By pressing more strongly, or dividing the nerve, the 
feeling is further impaired or altogether destroyed. Similar effects 
may be produced by a tumour, ligature, effusion, or other cause 
pressing on a nerve in its course. Disease of the nerve, or of a 
part of the spinal or cerebral matter connected with it, may like- 
wise modify the sensation of parts. Thus inflammation of the 
sheath of the ischiadic or trifacial nerves may cause first neu- 
ralgic pain, and afterwards numbness in the parts to which the 
nerve is supplied. There are other painful affections which are 
to be considered, and treated as cases of exalted sensibility, such 
as the irritable (as Dr. Billing observes, erroneously so called) 
breast, testicle, uterus, &c. 

133. But the function of sensation, as other functions, depends 
on the supply of blood to the extreme distribution, as well as to 
the trunk and origin of the nerves. Hence if blood does not 



DISEASED SENSIBILITY LOCAL. 81 

circulate freely through a limb, the sensations are impaired; and 
if it passes too freely, the sensibility is exalted, and there may be 
itching, tenderness, or even pain. In organs of special sensation, 
the senses are modified, together with the common feeling: thus 
in disease of the optic nerve or retina, there will be intolerance of 
light, or specks and clouded vision, or even blindness; in the ear, 
ringing and beating noises, or deafness, besides the affections of 
common sensibility, itching, tenderness, and pain. 

134. At the orifices of passages into the interior, there are 
peculiar kinds of sensibility connected with the functions of in- 
gestion and egestion; these modified are elements of disease. As 
examples of such excessive sensibility, may be enumerated thirst, 
craving, nausea, tenesmus, and painful micturition: of impaired 
sensibility, anorexia, and paralysis of the rectum and urethra. 

135. When we come to internal parts, we have only to con- 
sider their sensibility when exalted by disease. We do not know 
that they naturally possess any feeling. Of the ordinary pro- 
cesses, as of the passage of food and fasces in the alimentary 
canal, of the movements of the lmigs, of the heart, and of the blood 
through the vessels, we are not conscious; but under the influence 
of disease we become painfully sensible of several of these mo- 
tions. This excessive sensibility is developed by inflammation, 
as in pleurisy, peritonitis, meningitis, &c, or by irritation, by me- 
chanical or other means, as in colic, biliary and urinary calculi, 
gastralgia, perforation of the stomach or intestines, &c. It is very 
remarkable that pain from these, which is perhaps severer than 
any, should arise so suddenly in parts which give no evidence of 
common feeling. 

136. In many instances we are to regard pain merely as a 
symptom to be removed only by means which remove its cause, 
the lesion which produces it, (§ 132, 133;) but in many cases, on 
the other hand, although a symptom, it constitutes a chief de- 
limit of the disease, and one against which remedies must be 
expressly directed. Thus it is in neuralgia, gastralgia, nephralgia, 
colic, dysmenorrhcea, and perforated intestine. So long as the 

-^ive pain lasts, all the functions suffer, (§ 69,) faintness and 
exhaustion ensue, and if no relief comes, the prostration may be 
l;it;il. Here to mitigate or remove the pain is a first and pressing 
indication. Again: in some other cases where the pain is less 
severe, it may be very hurtful by interfering with important 
functions. Thus the stitch of pleurisy impedes the breathing; 
tin' |>;iin of tenesmus and the irritation of the stomach or wind- 
pipe cause efforts ;i r straining, vomiting, and coughing, so violent, 
thai the functions are thereby kept in a state of disturbance, and 
the strength is exhausted. Here ii may l"' necessary to treat 
promptly for the pain on account of its immediately pernicious 
effects. 



S2 ULTIMATE ELEMENTS OF DISEASE. 

137. Remedial measures. — Where excessive sensibility de- 
pends on inflammation, antiphlogistic measures will generally 
soon remove it. Where it lingers after the inflammation, is out 
of proportion to it, or is independent of it, then anodynes become 
the chief remedy. The most powerful of these are opium and 
its active principles; but these have morbid effects, (impairing the 
secretions,) (§ 70,) which sometimes render opiates less eligible 
than the weaker but safer narcotics, hemlock, henbane, stramo- 
nium, belladonna, Indian hemp, and aconite. These different 
anodynes are used both internally and externally.* Counter- 
irritation and warmth are also means of relieving pain. The 
pain of gastrodynia may often be removed by a sinapism to the 
pit of the stomach — that of colic and dysmenorrhea by hot fo- 
mentations, or bags of hot sand or salt, &c. In other cases, pain- 
ful feelings may be relieved by such pressure on the part as will 
counteract tension, and diminish without stopping the flow of 
blood through the part. 

13S. We are not possessed of equal means of restoring lost 
sensibility. Stimulant applications and frictions are serviceable 
where the defect arises from deficiency of circulation in the part; 
and strychnia or cantharides given internally, and electricity 
used topically, perhaps may have some little effect in exciting 
the functions of the nerves, but more doubtfully in regard to 
sensation than to motion. 



SECTION IV. 

DISEASED VOLUNTARY MOTION OR EXCIT0M0TI0N BY THE WILL. 

139. The function by which certain nerves convey the im- 
pulses of the will to voluntary muscles, may become disordered, 
and its phenomena constitute an element of disease. Some of 
these have already been noticed under the head of diseased irri- 
tability, (§ 113;) and it was diere observed that the error is more 
commonly in the nervous influence which excites the muscles, 
than in the property of the muscles themselves. This is the case 
in most convulsive diseases, and in those cases of paralysis which 
depend on injuries of the voluntary nerves, or of those parts of 
the spinal and cerebral system which are the channels of volition. 
A brief illustration of these diseases will suffice to correspond 
with those of diseased sensation. 



* Painful affections occurring with a weak circulation are sometimes removed 
by tonics: thus neuralgia has been successfully treated with iron, hemicrania 
with quinine, &c. 



DISEASED VOLUNTARY POWER. 83 



DISEASES OF GENERAL VOLUNTARY POWER. 

140. Voluntary motion may be said to be generally in excess 
when the brain is excited by strong emotions or feelings, (§ 66,) 
by stimulating liquors, (§ 55,) and by the hurried circulation of 
phrenzy or phrenitic delirium. Hysteria, as usual, can supply 
like examples. The strength and rapidity of movements dis- 
played in hysterical cases are sometimes astonishing: yet they are 
obviously voluntary movements, for they are often performed 
rhythmically, or to a time, as in dancing. The dancing of taran- 
tulism, and the extravagant exertions of the fanatics called jump- 
ers, would seem to arise from an erethism of the part of the 
nervous system concerned in voluntary motion. Short of disease, 
a naturally high voluntary power is evinced in the energetic and 
active movements of some persons, who excel and delight in 
feats of strength or agility. Mere muscular strength will not suf- 
fice without nervous energy to act on it. 

141. General volition is more or less defective in apoplectic 
coma, stupor from various causes, pressure, congestion, narco- 
tism, &c, where other nervous properties are also impaired, 
(§ 129;) in trance, catalepsy, and nightmare; in a less degree also 
in cases of lethargy and weakness from over- exertion, (§ 68.) 
This defect may be sometimes suddenly induced by terror, sur- 
prise, &c., (§ 69,) which for a time take away the power of mo- 
tion. Hence the fabulous power of the Gorgon's head; and the 
signification of the expressions petrified with astonishment, 
motionless ivith terror, fascinated, and the like. The muscular 
power (§ 110) is not lost in these cases, but only the influence of 
the mind over it — that is, volition. 

142. Examples of perverted, voluntary poiver may be found 
in chorea, delirium tremens, and some analogous affections called 
hysterical. In these volition may be often also defective, (§ 141,) 
but it. is not always so; only each act of the will is perverted in 
its performance. The will sets muscles in motion, but the 
wrong muscles, or too many, too forcibly, or irregularly, so that 
the resulting action is not in accordance with the will. 

PARTIALLY DISEASED VOLUNTARY POWER. 

143. We can scarcely point out examples of partial excess of 
voluntary motion. The convulsive movements of voluntary 
muscles are quite involuntary, and have been noticed under the 
head of diseased muscular action, (§ 113;) but it was there men- 
tioned that they may arise from irritation of the nerves, inde- 
pendent of the will. Hysteria does, however, furnish examples 



84 ULTIMATE ELEMENTS OF DISEASE. 

of excessive movements of one limb or part of the body, so far 
amenable to mental influence as to be excited and timed by ideas 
in the patient's mind. These cannot be said to be wholly in- 
voluntary; but are the result of a wilful impulse, perhaps too 
strong to be easily resisted. 

144. Partial defect of voluntary power is very common, and, 
like local defect of sensibility, may be traced to partial disease of 
the motor (anterior) columns of the medulla and prolongations; 
or to disease of, or pressure on, a motor nerve in its course; or 
to a disordered condition of the ultimate distribution of the 
nerve, or of the circulation supporting its function. Thus 
paralysis of voluntary motion in an extremity or a whole side, 
(hemiplegia,) may arise from disease in the optic thalamus or 
corpus striatum of the opposite side: these being the channels of 
communication between the cortical seat of the sensorial functions 
and will, and the motory columns and nerves. Lesions of the 
motory (anterior) columns within the spine may intercept more 
or less the voluntary power over those parts supplied with spinal 
nerves from below the diseased point. Thus a lesion in the lower 
cervical portion may paralyze the upper and lower extremities 
and whole trunk, (except the diaphragm, which is supplied by 
the phrenic nerve:) a lesion in the dorsal or lumbar portion 
paralyzes only the lower half of the body, (paraplegia,) or lower 
extremities. Or the disease may be more partial, paralyzing one 
nerve only, as the portio dura, causing distortion of the features; 
or the ninth nerve, causing difficult articulation, &c. The lesion 
of the nervous textures here alluded to may be structural 
change, as tumours, effusions, or haemorrhage, or only an altered 
state of the blood-vessels of the part. Severe cold or continued 
pressure will impair voluntary power in a limb, by checking the 
free flow of blood, which is essential to the proper function of 
the nerves as well as of the muscles. Hysteria affords numerous 
examples of volition impaired in parts, as in loss of voice and 
power of articulation, retention of urine, paralysis of limbs, &c: 
these affections may come on quite suddenly, and as suddenly 



145. Remedial measures. — Excessive voluntary power is 
rarely an element of disease for separate treatment. As part of 
the excitement of the nervous centres, it may be reduced by seda- 
tives of different kinds — depletion, antimonials, and cold to the 
head, being the most effectual where the excitement is attended 
with determination of blood; morphia, and other narcotics, where 
the excitement is more purely nervous. The violent exertions 
of maniacs are wonderfully controlled by the cold douche to the 
head, sometimes with nauseating doses of tartar emetic. 



DISEASED VOLUNTARY POWER. 85 

146. The treatment of defective volition will consist in means 
calculated to excite the nervous centres directly, or through the 
medium of the circulation. Agents which restore free circulation 
of healthy blood through the nervous centres and branches gene- 
rally improve voluntary power. Thus a stimulant draught may 
raise the failing strength of a person fainting. By warmth and 
friction, one who is benumbed with cold recovers the use of his 
limbs. Sleep or rest will restore voluntary power exhausted by 
fatigue. Sudden and powerful mental excitement, as by a fright, 
has been known to restore voluntary power which had been long 
lost. A lady who for several years had lost the use of her lower 
extremities, was startled by a rat running near her: having an 
extreme antipathy to the animal, she made an effort, and sprang 
"on a table near; the power, however, did not remain, for she 
could not get down again. A. more permanent cure of impaired 
volition has been effected by the excitement of religious fanati- 
cism, as in the cases of the supposed miracles of Prince Hohenloe, 
Miss Fancourt, &c. As we have found that such mental excite- 
ment sometimes causes excessive voluntary motion in healthy 
persons, (§ 140,) so we perceive that, suddenly applied, it may 
restore it where defective. 

But sometimes volition is defective from pressure on, or con- 
gestion in, the brain, which prevents the due motion of the blood 
through it, as in plethoric lethargy, or apoplectic coma: here de- 
pletion and derivation may sometimes restore the power. In the 
lethargy of narcotism and asphyxia, the volition is often restored 
by means which excite strong sensations and reflex actions, as 
dashing cold water on the face and chest, ammonia or other 
stimulating vapours to the nostrils, electric shocks, stinging with 
nettles, &c. The trance or coma of hysteria may often be re- 
moved by a turpentine injection, or croton oil purgative, which 
acts both as a revulsive to the vessels and a stimulant to the 
. nerves. 

Perverted volition will require various treatment according to 
its kind; that of delirium tremens being corrected by narcotics, 
especially opium; that of chorea, by nervous tonics, especially 
iron and zinc. 

147. The treatment of locally diseased voluntary power will 
generally commence with attempts to remove its cause, which we 
have found to vary too much both in seat and nature to admit 
of an elementary statement of remedial measures. Those for 
defective voluntary power comprehend the complex subject of 
the treatment of paralysis, which commonly comprises means 
calculated to restore to its proper state the circulation through 
the affected part of the nervous system, and sometimes, also, 
8 



86 ULTIMATE ELEMENTS OF DISEASE. 

means which stimulate this part by exciting agents, such as elec- 
tricity, stimulating frictions, and blisters; and strychnia and can- 
tharides given internally, which are supposed to have a directly 
stimulant action on the motory columns and nerves. 



SECTION V. 

DISEASES OF REFLECTED AND SYMPATHETIC NERVOUS 
INFLUENCE. 

148. The nervous property by which various movements and 
processes connected with organic life are excited, may be dis- 
ordered, and its alterations are remarkable constituents of many 
diseases. The contractions of all the sphincters, of the oesopha- 
gus, the glottis, the iris, the eyelid, and the regular action of the 
muscles of respiration, seem to be sustained, independently of the 
will, by a nervous influence conveyed by afferent nerves from 
the respective parts or surfaces to the spinal marrow, and re- 
flected from it through the efferent nerves to the muscles con- 
nected with these parts. The full establishment of this physio- 
logical principle we owe to Dr. Marshall Hall. 

149. The increase of this involuniary ecccitomotory power 
is instanced in the spasm of the throat, and sometimes of the 
sphincters, in hydrophobia, tetanus, and some hysterical affec- 
tions. The hurried respiration, the convulsive cough, violent 
retching, and hiccup, which are occasionally presented in these 
and other nervous diseases, may also be in part traced to an un- 
due influence of the excitomotory nerves of organic life. These 
actions are sometimes excited by sensations, (§ 134,) as the 
breathing by feeling of want of breath, cough by tickling in the 
air-passages, retching by nausea, &c; but it is where either there 
are no such sensations, or where they bear no proportion to the 
violence of the actions, that we are warranted to conclude that 
the excitomotory function is itself exalted. 

A similar exaltation of the excitomotory function, independent 
of sensation and volition, is exemplified in the voluntary muscles, 
when they are deprived of sensation and voluntary motion by 
disease in the brain itself, or cutting off communication between 
the brain and spinal cord, without materially injuring the cord 
itself, (§ 118.) Thus, in paraplegia from injury of the upper part 
of the spine, the excitomotory power of the nerves of the lower 
extremities is exalted, and tickling, or mere touching the soles of 
the feet or legs, will produce convulsive motions, although all 



DISEASED EXCITOMOTION (itEFLEx). 87 

voluntary power and sensation be wholly lost.* This phenome- 
non is sometimes so readily produced as to be a cause of much dis- 
turbance to the patient, the mere touch of the bedclothes exciting 
troublesome startings. The same thing occurs in hemiplegia, but 
less distinctly, as the cerebral influence is rarely here so com- 
pletely intercepted. I have known, however, the convulsive 
motions of a paralyzed limb so violent, in a hemiplegic patient, 
that it was necessary every night to fasten it down to the bed- 
stead to enable the patient to get sleep. 

Another instance of involuntary excitement of the muscles 
occurs in the symptom of "fidgets," which often arises from irri- 
tation reflected from the lower part of the intestinal canal, or from 
the uterus. 

150. Under this head we must also glance at convulsions, 
which, according to Dr. M. Hall's views, and consistently with 
the phenomena of disease, must be referred to an irritation of the 
true spinal system. This irritation may be centric, as in epileptic 
and apoplectic convulsions from disease in the head, and those 
from loss of blood; in which cases, the spinal and prolonged me- 
dulla being excited, the excitomotory influence radiates to the 
limbs and muscles generally; or it may be eccentric, commencing 
with irritation of the extremities of some efferent nerve, which 
transfers it to the spinal centre, whence it is again reflected gene- 
rally or partially. Such are the convulsions arising from teething, 
uterine, intestinal, and renal irritation; and a slighter degree is 
exemplified in the rigour caused by the sudden impression of cold 
on the surface, or by passing a bougie into the urethra of a nerv- 
ous person. 

151. Partial spasms caused by reflected irritation are exem- 
plified in cramp in the legs, from acrid matter in the colon, in 
diarrhoea and cholera; retraction of the testicle from calculus or 
inflammation of the kidney; spasm of the glottis from a bone 
sticking in the pharynx, &c. More familiar examples of the 
same class of reflected irritation are found in sneezing from irri- 
tation of the nares, winking from irritation of the conjunctiva, 
coughing from irritation of the glottis, retching from irritation 
of the fauces, efforts to evacuate the rectum and the bladder from 
irritation of these parts respectively. But it must not be for- 
gotten that all these latter examples are connected with obvious 

* The same phenomenon is exhibited in a high degree in the decapitated 
frog, in which touching the surface excites convulsive movements. A still 
more interesting illustration sometimes occurs in animals or persons whose 
cerebral power (sensation and voluntary motion) is impaired by opium or other 
narcotics; spasms or convulsive actions of the muscles being induced by tick- 
ling or pinching the skin, which shows the excited state of the rellex or spinal 
function. 



88 ULTIMATE ELEMENTS OF DISEASE. 

sensations; and they imply increased excitomotory influence only 
in those cases in which they are out of proportion to these sen- 
sations. 

152. But some of the most remarkable instances of reflected 
irritation are displayed in the involuntary muscles, the heart, and 
the muscular fibres of the air-tubes and intestinal canal. Thus 
inordinate action of the heart (palpitation) is commonly caused 
by irritating matters in the stomach or intestines, kidneys, or other 
viscera, (§51, 54;) nay, we shall afterwards find, that the heart 
is liable to be excited by considerable irritation in any part of the 
body, as in fever and constitutional disorder. The spasm of the 
intestines in colic is induced by reflex irritation resulting from 
acrid matter in them; for if it were from direct irritation alone, 
the spasm would only affect the part touched by the offending 
matter.* The spasm of the bronchi, so suddenly occurring in 
spasmodic asthma, also sometimes arises from intestinal irritation. 
It has long been supposed, and is still a common opinion, that 
these morbid sympathetic movements are due to the direct 
nervous connection which the great sympathetic nerve establishes 
between the respective organs; but this supposition assumes, 
what experiment has not proved, that the ganglia of this nerve 
are either centres of reflection,! or sources of nervous influence, 
which is still more inconsistent with the latest researches. So 
far as we yet know, the spinal marrow is the centre of reflection 
in these as in all other examples of reflex action which we have 
been considering, although the sympathetic be the medium of 
communication.! 

153. When phenomena of inordinate reflex actions are general 
or extensive, as in convulsions, tetanus, and paraplegia, we must 
refer them to an undue excitement or erethism of the spinal and 
prolonged medulla; but the more partial examples may arise 
from similar excitement of a small portion of it only, or of the 
incident (afferent) nerve of the part which occasions the pheno- 
menon, or of the excitomotory (efferent) nerve of the part which 
exhibits the phenomenon. 

If we seek to know the causes of this excitement, we shall find 
that, as in excess of other vital properties, it is sometimes refer- 
able to an increased flow of blood through the spinal marrow or 
its nerves, or the branches of the sympathetic nerve. Thus the 
early stage of inflammation of the spinal cord, or of its sheath, is 
attended with convulsions or tetanic spasm. It is very probable, 
that the spinal excitement (convulsions) occurring in epilepsy 
and apoplexy, is in part due to the flow through the medulla 

* Mailer's Physiology (by Baly), p. 737. f Volkman, Muller, p. 738. 

* Valentin, Carpenter's Human Physiology, Am. Ed. p. 150. 



DISEASED EXCITOMOTION (REFLEX). 89 

being increased in proportion as that through the brain is im- 
peded: a consideration of the causes of convulsive paroxysms, 
and of the distribution of the vertebral arteries, much counte- 
nances this supposition. But in many cases the excitement 
seems to be of a more direct nature. Strychnia in a poisonous 
dose excites the medulla so speedily, causing tetanic spasm, that 
its effect can scarcely be due to increased flow of blood. So, too, 
we know, that mechanical irritation of the spinal marrow or of 
its nerves will cause convulsive motions; and we find this exem- 
plified in the effect of tumours and spicula of bone in the spinal 
canal, in the head, or in the course of nerves. But nothing ex- 
hibits this element of nervous irritation (apart, so far as is yet 
known, from vascular influence) so fearfully as traumatic tetanus. 
The irritation here begins in a distant nervous branch, and is 
propagated to the medullary centre, the excitomotory function of 
which at length exhibits a state of erethism, which destroys life 
either directly by tonic spasm (§ 114) of the muscles of respira- 
tion, or by exhaustion. Another cause, which may be fairly 
assigned ibr increase of the involuntary excitomotory property, 
is accumulation by rest. This causes the augmentation of this 
property in the medulla in narcotism, and in injuries of the spine, 
(§ 1-19,) which suspend the exhausting influence of volition on 
the whole or part of the marrow, in which the nervous energy 
therefore accumulates, and becomes unusually abundant. There 
can be little doubt that sedentary habits, and too much indulgence 
of sleep, likewise may cause an accumulation and morbid excess 
of nervous power, and develop convulsive and spasmodic symp- 
toms, which are the result of its overflow. 

154. Defect of the reflex, or involuntary excitomotory function, 
is exemplified in the paralysis which affects the sphincters, the 
eyelids, (lie muscles of respiration, and others whose normal 
action depends on this function, (§ 14S.) When this is generally 
and considerably impaired, the result will be fatal, because the 
respiration, deglutition, and other actions essential to life, suffer. 
It is by affecting these actions that apoplectic coma and nar- 
cotism prove fatal; and the state of sinking from excessive weak- 
ness or depressing causes, also exhibits the failure of the reflex 
power, when the urine and fasces are voided involuntarily, and 
tip' hivnthing is irregular and gasping, being forced by voluntary 
effort. Prom failure of the same power, coughing and expecto- 
ratioii hccomc inolliciont in clearing the air-passages of mucus; 
hence the bronchial and tracheal rattles which precede death. 
As those movements are the last to fail, so in recovery from as- 
phyxia, syncope, and other similar states of partially suspended 
animation, the actions connected with the reflex function are the 
8* 



90 ULTIMATE ELEMENTS OF DISEASE. 

first to return with the restoration of life; and thus vomiting, 
coughing, and sneezing, are among the early signs of reaction. 

155. Remedial measures. — As with other instances of exalted 
nervous function, so with excessive reflex action, when de- 
pendent on inflammation, or determination, or congestion of 
blood in the medulla, the remedies for these are appropriate 
against this effect: and the same measures in smaller degrees are 
often useful in hysterical affections when these occur with ful- 
ness of habit, and spinal tenderness. In case of irritation of the 
nervous centres, more purely nervous, as that of tetanus, hydro- 
phobia, poisoning with strychnia, &c, a narcotic or sedative, 
which may lower the exalted function, is the desideratum. We 
possess some agents which powerfully reduce the power of the 
spinal system, and cause general relaxation of the muscles, such 
as hydrocyanic acid, woorara, Indian hemp resin, and conium: 
these drugs may themselves destroy life, by arresting the function 
of the medulla oblongata in maintaining respiration; but this 
very poisonous action, and the sedative effect which one (hydro- 
cyanic acid) also has on the heart, render the remedy almost as 
dangerous as the disease.* For slighter irritation of the medulla, 
however, these medicines in moderate doses, and a few others 
like them, are often beneficial. Thus hydrocyanic acid is a very 
efficacious remedy in vomiting, nervous palpitation, and hiccup; 
it is also useful in convulsive cough, in which, however, the ex- 
tracts of belladonna and stramonium are still more effectual, as 
they also are in spasmodic asthma. The same medicines and 
opium are often beneficial in relieving the spasms of colic, dysen- 
tery, and dysuria. 

Some medicines, which act as stimulants to the heart and ves- 
sels, and to the cerebral functions, seem to operate as sedatives 
to the medullary system: these are the stimulant antispasmodics, 
such as aether, ammonia, musk, essential oils, gum — resins, creo- 
sote, alcohol, &c, which are useful remedies in spasmodic and 
convulsive affections in weak subjects, without inflammation; 
they probably operate by giving vigour and equality to the cir- 
culation. External heat and counter-irritation act hi a similar 
way. 

There is another class of remedies which have some power in 
reducing the excitability of the spinal excitomotory system — 
namely, tonics, especially those prepared from metals; but the 
operation of these is gradual, and therefore probably indirect. 
The sesquioxide and other preparations of iron are efficacious in 

* From the late accounts of Dr. O'Shaughnessy and others, the resin of the 
Indian hemp seems to be more powerful than any other remedy in relaxing 
tetanic spasm, and in at least alleviating the symptoms of hydrophobia. 



DISEASED REFLEX SENSATIONS. 91 

chorea, and perhaps in the more chronic forms of tetanus. 
Nitrate of silver, sulphate and oxyde of zinc, and sulphate of 
copper, have been found to diminish the attacks of epilepsy, hys- 
terical convulsions, spasmodic asthma, and cough, and other con- 
vulsive affections. The more obvious operation of these remedies 
is on the vascular system, to which they prove astringent and 
tonic, and it is uncertain whether their beneficial action in nerv- 
ous diseases is of this kind only, equalizing the circulation, or 
whether they exercise any more direct influence on the nervous 
system. The same question is open with regard to certain regimi- 
nal means of reducing nervous excitability, such as cold bathing, 
country air, and change of air, and exercise. The latter, how- 
ever, no doubt, may be useful by exhausting the superfluous 
nervous power (§ 153) by another channel, voluntary motion. 

REFLECTED OR SYMPATHETIC SENSATIONS. 

156. Clinical observation teaches us that not merely motory 
impressions, but those also which cause sensations, may be re- 
flected, so that when the impression is made on one part, the 
sensation is experienced in another. I do not allude to the fact 
that a stroke on the nervous trunk produces feelings referred to 
its branches, but I advert to impressions on the ultimate distri- 
bution of one nerve producing sensations in parts supplied by 
another nerve, or by another branch of the same nerve. The 
following are examples of this kind. Touching the external 
auditory meatus causes a tickling sensation in the glottis. A cal- 
culus in the bladder produces pain referred to the extremity of 
the penis. Ascarides in the rectum cause itching of the anus, 
and sometimes of the pudenda. Congestion of the liver some- 
times is accompanied by pain in the right shoulder-blade; and a 
disordered state of the stomach, occasionally with pain in the left 
shoulder-blade. The pains of angina and gastrodynia often ex- 
tend to the whole chest, and the former especially radiates to the 
left arm. Severe frontal headache is almost instantly caused in 
some persons by acid ingesta, in others by eating ice. Irritation 
of the intestines, as in cholera and colic, (especially painter's 
colic,) frequently causes pain and tenderness in the legs and feet, 
even when there has been no cramp or other excitomotory phe- 
nomena. Temporary neuralgic affections seem to be due to simi- 
lar causes. 

In these and other instances that might be cited, the sensations 
cannot be referred to direct nervous communication, but to an 
influence reflected, probably from the spinal centre only. 

The sympathies subsisting between some organs arc very re- 
markable, and none more so than between the breasts and the 



92 ULTIMATE ELEMENTS OP DISEASE. 

uterus. Applying the infant to the breast often induces uterine 
pains in women recently delivered; and the catamenial discharge 
has been excited in some instances by stimulating applications to 
the breast. 

157. The remedies most effectual in relieving reflected sensa- 
tions are — 1st, those that remove their irritating cause; and 2d, 
those that deaden sensibility, (§ 137,) anodynes. The peculiar 
efficacy of trisnitrate of bismuth and hydrocyanic acid in reliev- 
ing gastrodynia and some kinds of angina, is, however, not ex- 
plicable by any narcotic quality. 



SECTION VI. 

DISEASES OF SECRETION. 

158. The power of secretion appears to be a vital endowment 
of the ultimate cells or molecules of secreting structures.* It is 
uncertain whether the process comprises the formation as well as 
the separation from the blood of the peculiar matter of the secre- 
tion. In the case of the mine and bile, it would seem that they 
may be formed in the blood without the aid of the secreting 
organs; for urea is found in the blood of animals whose kidneys 
have been prevented from acting by ligature of their blood- 
vessels, or by extirpation; and both urea and some of the princi- 
ples of the bile (colouring matter and cholesterine) are found in 
the blood and in various parts of the body when the kidneys and 
the liver respectively have been disabled by disease. But whether 
the secreting structures assist in the formation, or only affect the 
separation, of the matters which they eliminate, their elective 
power is equally a peculiar attribute of life, and is at present in- 
explicable by any physical or chemical law. I have for the last 
twenty yearst advocated the opinion recently advanced by Dumas 
and Liebig, that the formation of the principles of the chief secre- 
tions takes place through chemical affinities, especially those of 
the absorbed oxygen and the constituents of the blood, controlled 
by vital agencies; but this view leaves still as a vital property the 
power which the liver has to separate bile; the kidneys, urine; 
mucous membranes, mucus, &c. 

We are thus led to consider secretion as a peculiar property of 
me secernent structures, just as irritability is of muscular fibre, 

* Mtiller De Glandularum penitiori structura. Henle, Allegemeine Anatomic 
Goodsir, Trans. Royal Society of Edinburgh, 1842. Bo\rrhan, Phil. Trans. 1842. 

f In a thesis, Be sanguine ejusque mutalionibus, Edin. 1824. See also Med. 
Gaz. September and October, 1835, 



DISEASED SECRETION. 93 

(§ 110;) and as such its disorder constitutes a primary element of 
disease. In doing this we avoid the hypothesis of some physiolo- 
gists, who ascribe secretion to nervous influence, a notion by no 
means accordant with numerous facts. 

159. In reviewing the disorders of other vital properties, we 
have found that many of them are plainly referable to changes in 
the supply of blood to their respective textures, (§ 113, 127, 131, 
133, &c.) The same cause may be found still more decidedly to 
operate in producing variations in the process of secretion. The 
blood being the material from which the secreted matter is sup- 
plied, variations in the quantity or quality of the blood will surely 
alter the quantity or quality of this product. Thus when an in- 
creased flow of blood takes place to a mucous membrane, its 
secretion is increased, and sometimes rendered more acrid than 
usual; whilst a congested state of the same membrane or of the 
liver may impair the secretion. Hence the most common causes 
of altered secretion are those which operate on the sanguiferous 
system and its contents. 

160. But affections of the nervous system, and of the mind, 
which acts through that system, may also affect the secreting pro- 
cess, as shown by the mouth watering at the sight or thought of 
a good meal; the bilious diarrhoea that mental agitation will cause 
in some persons; the large flow of limpid urine after nervous ex- 
citement; the tears excited by grief or other strong emotion; the 
unwholesome quality of a nurse's milk when she is in a state 
of anxiety or apprehension. We do not know whether these 
influences act by altering the flow of blood, (§ 159,) or by more 
directly modifying the vital property of the secreting organ, 
(§158.) 

161. The importance of this element of disease maybe esti- 
mated, from the ubiquity of the process of secretion, which in- 
cludes both excrement itious (only to be voided out of the system) 
and rccrementilious products, (those concerned in digestion, assi 
mi l;i I ion, and nutrition,) and also from the extent of its effects in 
relation both to the destination of the secretion, and to the blood 
from which it is separated. These may severally be excessive, 

DEFECTIVE, aild PERVERTED. 

162. Excessive secretion of any kind, whether bile, urine, 
mucus, &c, may weaken by the drain which it causes from the 
mass of blood, (§28, 71;) and this effect will be in proportion to its 
quantity, and especially to the animal matter which it contains. 
Thus ;in excessive secretion of bile weakens more than that of 
thin mucus. I hit each secretion may have peculiar effects con- 
nected with its office and composition; and these effects may be 

forwards , on the parts to which thesccretion goes, and backwards, 
on the organ and the blood from which it is formed. 



94 ULTIMATE ELEMENTS OP DISEASE. 

163. The forward effects of an excessive secretion of bile de- 
pend on its stimulating properties. It irritates the intestinal tube, 
causing a bilious diarrhoea or cholera. The symptoms of this 
consist in an exaggeration of those properties of the alimentary 
canal which have already been described as elements of disease. 
Thus the bile irritating causes increased irritability, (§ 113,) and 
more rapid motion of the matter through the tube; pain from 
exalted sensibility, (§ 134, 135;) vomiting, straining, and cramps, 
from exalted excitomotory function, (§ 149, 151;) profuse mucous 
secretion from excited secernent function, (§ 162.) An excessive 
secretion of mucus in the intestines may cause only simple diar- 
rhoea; but in the bronchi it may occasion dyspnoea and cough, 
and, if not expectorated, may suffocate. Excessive secretion in 
the stomach may cause pyrosis or waterbrash, the liquid being 
sometimes acrid, and occasions nausea and vomiting as well as 
eructation. The excessive secretions of secreting organs generally 
may amount to a flux or profluvium; and those from internal 
enclosed serous surfaces or cellular texture constitute various 
dropsies. These produce different effects according to their 
situation. 

164. But excessive secretion may also have effects backwards, 
on the organs, and on the blood from which it proceeds. Ex- 
cessive secretion often weakens the vital properties of the organ, 
so that, in its proper function, it subsequently becomes torpid. 
Thus after diarrhoea the bowels often become torpid from defect- 
ive secretion. So, too, in cases where an excessive secretion 
continues for a long time, it generally is impaired in its quality 
from a similar cause. 

165. Excessive secretions, if abounding in animal matter, may 
not only reduce the mass of the blood, but also affect its compo- 
sition. Thus bile and urine, which differ much in composition 
from the blood, if separated in unusual proportions, must leave 
the blood modified. Urine contains a great preponderance of 
azote; and its excessive formation from the principles of the 
blood would leave a predominance of hydrogen and carbon in 
tins fluid. The bile, again, abounds in hydrocarbon; the copious 
removal of which would leave a superfluity of azote. It may be 
objected to this statement, that, according to the opinion of some 
chemists, the urine and the bile are not formed from the con- 
stant elements of the blood, but from materials derived from the 
food, and from the decay or transformation of the tissues. To 
this it may be replied, that this opinion is at present no more 
than hypothetical; and should it prove to be true, it would not 
affect the undoubted fact, that the secretions of the liver and of 
the kidneys are intended to balance one another, and the removal 
of carbon from the lungs; and that whether the materials from 



DISEASED SECRETION. 95 

which these eliminating processes are supplied be the principles 
of the blood itself, or the decayed constituents of tissues, or mat- 
ters derived from the food, the co-operation of all these processes 
will be generally required to maintain a uniformity in the com- 
position of the circulating fluid; so, too, if one of these processes 
is more active than the others, the blood must suffer by the ex- 
cess of those matters which the less active processes allow to 
accumulate in it, (§ 70, 71.) A clinical illustration of this posi- 
tion may be fomid in cases of bilious diarrhoea or cholera. This 
flux of bile is either accompanied by a highly loaded state of the 
urine, or by fever; in the latter case, the fever does not subside 
until the urine becomes very copious, or deposits an abundant 
sediment. The most probable interpretation of this fact is, that 
the excessive secretion of bile disorders the composition of the 
blood; so long as the kidneys rectify this disorder by separating 
in greater abundance the solid contents of the urine, no fever re- 
sults, but if the kidneys fail in this task, fever ensues, and con- 
tinues until they accomplish it; then a free secretion and copious 
deposit is symptomatic of the decline of the fever. 

166. The remedial measures that are serviceable in cases of 
excessive secretion will illustrate the view that has just been 
given of the balancing office which the secretions all fulfil. In 
so far as excessive secretion is dependent on the quantity and 
quality of the blood, (§ 159,) the treatment should be addressed 
to this element; by depletion, derivation, and evacuation, in cases 
of congestion or determination of blood; and in such cases the 
excessive secretion should not be hastily checked, as it may be a 
natural means of relief; nay, in some cases, it may be most speed- 
ily arrested by means which for the time increase it: thus a large 
dose of calomel will sometimes, after first purging, stop a bilious 
diarrhoea connected with an engorged liver, which astringents 
fail to check. But where the excessive secretion proceeds more 
from nervous and other sources of irritation, (§ 160,) and causes 
weakness and disturbance of the functions, it becomes a more 
immediate indication to check it. Secretions are to be diminished 
by means which act as general tonics or astringents, (§ 124,) and 
by others which operate only on particular organs. Of the for- 
mer class are cold applied to the part, and common astringents, 
such as alum, superacetate of lead, sulphates of zinc and copper, 
gallic acid and tannin, and substances which contain them, as 
nutgalls, oak bark, rhatany root, catechu, &c, mineral acids, &c. 
These act most surely by direct application, as in their use for 
diarrhoea, leucorrhoea, &c; but they seem to have some effect 
also through the medium of the circulation, as when taken inter- 
nally they reduce the secretion in the air-passages and skin. Of 



96 ULTIMATE ELEMENTS OF DISEASE. 

the agents which, without a general astringent effect, more spe- 
cifically diminish the secretion of particular organs, may be men- 
tioned opium, which remarkably lessens the secretion of the liver, 
and sometimes that of the kidneys. 

If an excessive secretion have already caused febrile disturb- 
ance, great advantage will be found to result from the use of 
means which increase other secretions, and thus restore the ba- 
lance before explained, (§ 165.) Thus in bilious cholera, saline 
diuretics and diaphoretics are highly serviceable. In renal irri- 
tation with copious secretion of lithic acid, blue pill, which aug- 
ments the secretion of bile, is often beneficial. These means may 
be supposed to operate partly as derivants; but the manner in 
which they remove the febrile irritation, after the reduction of the 
excessive secretion, renders it most probable that they act also by 
removing from the blood dregs left by the inordinate separation 
of the matter of the single secretion which has been in excess, 
(§ 165.) No practical physician can doubt that we possess medi- 
cines which often augment the secretions of particular organs, 
(mercury that of the liver and salivary glands, colchicum that of 
the kidneys, &.c.) yet there is a limit to the operation of these 
agents; but this limit may be increased by simultaneously acting 
on other organs which maintain the balance. Thus in any dis- 
turbance of the secretions, especially if it continue long, combina- 
tions of medicines are much more useful than those fulfilling one 
indication only; and thus experience has sanctioned the practice 
of conjoining mercurials with diuretics, and antimonials with 
salines, &c. 

167. Defective secretion of any natural or habitual dis- 
charge (§ 70) may cause a fulness of the blood-vessels; a general 
fulness if the secretion be naturally copious; a local fulness if it 
be trifling in quantity. Thus defective secretion of urine or bile 
may cause general plethora, or extensive local congestions, which 
may end in dropsical effusions, fluxes, haemorrhages, or inflam- 
mations. Diminished secretion of tears or saliva would merely 
cause fulness and dryness of the parts immediately concerned. 

The morbid effects of defective secretion may be both forivards, 
on the parts for which the secretion is intended, and backwards, 
on the organ and on the blood from which it should be elimi- 
nated, (§ 162.) 

16S. Defective secretion of bile causes disorder in the latter 
stages of digestion. The neutralization of the acid in the chyme 
and the separation of the chyle, to which the bile seems to con- 
tribute, are imperfectly performed: sometimes colic and diarrhoea, 
sometimes costiveness, results from the defect. Deficient secre- 
tion of mucus in the intestinal canal and bladder would expose 



DISEASED SECRETION. 97 

their membranes to more irritation from their contents. Proba- 
bly deficient secretion of mucus on the respiratory membrane 
may lessen the facility with which the air and the blood act on 
each other. Insufficient secretion of cerumen in the ear, or of 
saliva in the mouth, impair respectively the hearing and the pro- 
cess of mastication. A want of synovia in the joints has been 
supposed to be a cause of their imperfect motion and subsequent 
inflammation. 

169. The effect of defective secretion in causing congestion of 
its respective organ, has been already noticed: the concomitance 
of congestion with defective secretion, in the case of the liver, the 
kidneys, and mucous membranes, is well known; but either may 
be viewed in the light of both cause and effect. 

170. The most remarkable of the backward effects of defective 
secretion are instanced in case of the secretions, (§ 70.) The 
distinctive materials of the secretions of urine and bile appear to 
be positively noxious, and poison the system if not separated 
from the blood. Thus the sudden suppression of urine or bile 
causes typhoid symptoms, extreme depression, and coma, which 
speedily end in death; and in such cases, urea, or the colouring 
matter of the bile, has been found in various organs. Where the 
suppression is incomplete, the poisoning process is more tardy: 
various functional and visceral derangements are produced, such 
as delirium or lethargy, dyspnoea, palpitation, vomiting, diarrhoea, 
dropsical effusions, structural degenerations, &c, which always 
prove fatal, sooner or later, if the defective excretion be not re- 
stored. In these gradual cases, still more remarkably than in 
those of more sudden suppression, some of the excrementitious 
matters may be detected in the blood and in other fluids and 
solids of the body. Thus in some structural diseases of the liver, 
the colour of the bile becomes manifest first in a yellow, and by 
accumulating, in a deep greenish colour in all the textures, con- 
stituting the yellow and the black jaundice. In granular degene- 
ration of the kidneys, in which scarcely any urea is excreted by 
these glands, this principle is found in the blood and various 
fluids of the body. * 

171. The excretions are defective in many idiopathic and symp- 
tomatic fevers; and there can be little doubt that many of the 
constitutional effects of these fevers are in great measure due to 
this important element. The. positively noxious properties which 
wcrementitious matter retained in the blood is known to possess, 
(§ 170,) must be taken into account when we attempt to explain 

* In the case of a patient of mine affected with ascites from disease of (lie 
heart, liver, and kidneys, Mr. Garrod obtained nearly four grains of nitrate of 

•■in ai nee of the peritoneal fluid, and a considerable quantity of bright 

yellow solid matter, probably bilious. 
9 



98 ULTIMATE ELEMENTS OP DISEASE. 

the states of constitutional irritation and depression, with perver- 
sion of functions, which fevers so generally present. The changes 
in the blood, manifest in some such cases by its fluidity and by 
petechial appearances, may also be in part referred to defective 
elimination of effete matter;* and it is when the secreting organs 
recover their power, and a diarrhoea occurs, or a copious discharge 
of highly loaded urine, that these appearances cease. It is a ques- 
tion how far severe mechanical injuries or shocks, (§ 52,) and ani- 
mal and other poisons, (§' 105, 57, &c.,) may operate by thus in- 
juring the vital powers by which the blood is continually purified 
from its own noxious products; but that this is a part of their 
mode of action seems almost certain from their effect in suppress- 
ing or impairing the natural excretions. 

There can be little doubt that a morbid element, which in its 
extremes acts so injuriously as to cause serious disorder, and even 
speedy death, must in slighter degrees be an important cause and 
constituent of disease; and I believe that gout, rheumatism, and 
many cachectic states leading to diseases of nutrition, degene- 
rations, dropsies, &c, are essentially connected with defective ex- 
cretion. 

172. Remedial measures. — Defective secretion maybe caused 
by deficient or excessive supply of blood to the part, as in various 
cases of anaemia, congestion, and inflammation, (§ 159.) In such 
cases it must be treated by the proper remedies for these con- 
ditions: thus stimulants may restore secretions scanty through 
a defective supply of blood; and depletion and derivatives may 
be the best remedies, when they are stopped by inflammation or 
congestion. 

173. But sometimes the first disorder is in the secreting struc- 
ture itself, (§ 158,) and may best be removed by agents which 
specifically increase the secretion, which common stimulants will 
not do. Thus mercury increases the secretion of the liver; col- 
chicum, nitre, and other diuretics, that of the kidneys; croton oil, 
jalap, sulphate of magnesia, and other purgatives, that of the in- 
testines; and this they do, however introduced into the system, 
whether by the mouth, through the skin, or injected into vessels 
or textures. These are important practical facts, however difficult 
they may be to explain; and their application to restore defective 
secretions is abundantly obvious. 

174. But these specific stimuli of the secreting organs, (§ 173,) 
if used in excess, or too long, may not only cause general weak- 
ness, but also exhaust the vital properties which they excite, 

* Purpura I have found to be often connected with hepatic congestion, and 
imperfect excretion of bile, and to be most effectually removed by remedies 
which promote the restoration of the proper secretion. 



DISEASED SECRETION PERVERTED. 99 

(§ 159;) and the result maybe a diminution either of the secreted 
fluid, or of its most characteristic constituents. Hence the long or 
excessive use of mercury causes torpidity of the liver; that of 
purgatives, imperfect action of the bowels; that of diuretics, scanty 
urine, or albuminous or watery urine, defective in urea. These 
facts point out the expediency of alternating or conjoining these 
different agents with others calculated to improve the vital pro- 
perties of the textures generally, which may often be affected by 
the medicines called tonic, and by regiminal means which improve 
and equalize the state of the circulation, (§ 124,) and preserve the 
digestive and assimilative functions in the best order. In illustra- 
tion of this position, I may refer to the acknowledged advantage 
of giving bitters with or after mercurial courses; chalybeates with 
or after saline aperients and diuretics, when these are long used; 
and these additions, which alone, or used at first, would check the 
secretion to be increased, now sustain it and render it permanent. 
Some medicines which are inferior in efficacy to those already 
named, are yet, in some instances, more eligible for chronic cases 
of defective secretion; because they are less exhausting, and com- 
bine some measure of tonic influence with that of increasing the 
secretions. As examples of this kind may be named taraxacum, 
preparations of iodine, sarsaparilla, nitric and nitro-muriatic acids. 
Courses of these medicines are sometimes of great efficacy in keep- 
ing free the secretions after they have been restored by more pow- 
erful means, (§ 173;) and they likewise often improve the functions 
of digestion and nutrition. 

175. Where defective secretions are not readily restored, the 
forward disorder (§ 16S) arising from their deficiency may be 
sometimes remedied by artificial substitutes. Thus, in defective 
secretion of bile, the action of the intestines has been promoted 
by exhibiting ox gall. Aloes and soap combined have been 
thought to supply the place of bile in some cases. Toasted bacon 
at breakfast has been supposed to have a similar effect; but it 
more probably excites the liver to increased secretion, as other 
fat matters do. 

Imperfect lubrication of the throat and larynx, and other mu- 
cous membranes, from defect of mucus, may be remedied by 
mucilaginous and demulcent matters. A dry state of the skin 
may be relieved by applications of oil or honey. 

17(1. Perversion of secretion often accompanies excess and 
defect of this process. In febrile diseases, the secretions of the 
kidneys and alimentary canal are altered as well as diminished. 
Inflammation and determination of blood change as well as in- 
crease the secretion from mucous membranes, rendering it more 
saline, and sometimes albuminous. The urine exhibits remark- 



100 ULTIMATE ELEMENTS OF DISEASE. 

able changes in quality: full living, stimulating beverages, and 
irritations of the digestive organs or kidneys, rendering it un- 
usually strong and acid; whilst low diet, great fatigue of body 
or mind, and chronic inflammation of the kidneys, generally make 
it pale and alkaline. Out of these morbid conditions may arise 
various further decompositions, with sediments and calculous 
concretions of different kinds, (§ 51, 53.) Concretions are like- 
wise formed from an altered state of the bile. The perspiration 
is also sometimes changed; thus it is very acid in rheumatism, 
and foetid in delirium tremens. 

177. Secretions which serve particular purposes, when altered 
may become unfit for these, and thus cause disorder: thus a thin 
acrid mucus irritates instead of protecting the membrane which 
secretes it, as in coryza and mucous diarrhoea; a viscid diy mucus 
clogs up and obstructs tubes which it was intended to lubricate; 
altered gastric juice causes indigestion; sebaceous matter of the 
skin may accumulate in its follicles, and cause irritation and in- 
flammation, &c, 

178. The remedies for perverted secretions (§ 176) are usually 
those which likewise increase secretion, (§ 172, 173.) Thus 
depraved secretions of the intestinal canal are often satisfactorily 
altered by continued purging; a turbid state of the urine is some- 
times removed by diuretics; too thick a state of the mucus of the 
air-passages is modified by expectorants, &c. But where the 
change depends on altered circulation in the part, the remedies 
must be suited accordingly. In some cases, tonics restore a 
healthy state of secretions; and in most instances of long-con- 
tinued perversion, tonics may be advantageously combined with 
medicines which increase secretion, (§ 174.) Such a combina- 
tion is presented in most of those remedial agents which have 
obtained the appellation of alterative, and which would seem to 
be especially suited to oppose to the diseased element under con- 
sideration, if they really possessed the virtues ascribed to them. 

Nutrition is also effected by the property of secretion, (§ 158;) 
but inasmuch as its changes cannot be understood without a pre- 
vious knowledge of the blood and its constituents, and involve 
the complex subject of structural disease, their consideration will 
be deferred. 

DISEASES OF THE CONSTITUENTS OF THE BLOOD. 

179. The pathological elements (§ 107) which we have hither- 
to considered are those of the vital properties of the elementary 
solids. We now proceed to examine the morbid changes of the 
blood. These, like those of the solids, may be often traced to in- 



. ELEMENTARY CHANGES OF THE BLOOD. 101 

dividual elements, of which the blood is composed, the changes 
of which must be viewed as ultimate elements of disease, and 
are therefore properly included in the present division. But as 
the blood also operates as a whole, compound indeed in itself, 
but simple in its influence on vital functions and structures, it 
forms a proper connecting link between ultimate: and proximate 
elements of disease. So, also, inasmuch as it is, in some respects, 
an organized compound, the materials of which are changed, 
together with its functions, and contributes to the production of 
change of structure in the solids of the body, the consideration 
of its changes will be a proper introduction to that of alterations 
in the circulation, which induce changes of structure, and thus 
lead to structural diseases themselves. 

180. We have found that blood is the support of all the vital 
properties; and in describing their variations, we have been 
obliged to refer frequently to differences in the supply or quality 
of this fluid, both as causes and as consequences of these varia- 
tions, (§ 113, 127, 131, 159, &c.) We have now to examine the 
properties of the blood itself, and, first, those which are most 
elementary, or referable to its respective constituents. 

The circulating blood consists of red particles, colourless glo- 
bules, and liquor sanguinis; but as the latter is compound in 
function as well as in constitution, it is necessary to specify its 
chief constituents. We have, then, to consider — 

1. The red particles, "^ 

"58, 



2. Fibrin and colourless globules, 

3. Albumen and other dissolved I ■ , - . 

animal matters, Jm excess, defect, and 

4. Oil, 

5. Salts, 

6. Water, 



alteration. 



181. Other changes affecting the entire blood are — 

7. Changes by respiration. 

8. by secretion. 

9. by nutrition. 

10. by foreign matters. 

182. The average natural proportions of the chief constituents 
of the blood, according to Lecanu, and adopted by Andral and 
Gavarret as a standard, are 127 red globules; 3 fibrin; 72 animal 
matter in the serum; 8 salts; 790 water.* 

* Annates de Chimie et Physique, Nov. 1840, p. 229. 
9* 






102 ULTIMATE ELEMENTS OP DISEASE. 

SECTION VII. 

RED PARTICLES. 

183. The red blood-discs appear to be the part of the blood on 
which its vivifying and calorific properties chiefly depend. Thus 
Prevost and Dumas found that animals bled almost to death 
could be restored by injecting into their veins a mixture of red 
particles and serum", even when the fibrin had been removed; 
yet the serum alone failed to produce any such effect. It is 
therefore to be supposed that the red particles are the part of the 
blood required in transfusion in cases of hemorrhage. Andral, 
Gavarret, and Delafond, remarked that in domestic animals the 
vigour and beauty of the animal were proportioned more to 
the amount of red particles in the blood of the animal than to 
any other constituent; and that improvement of a breed by 
crossing was marked by an increased proportion of this ele- 
ment.* The red particles are supposed, by Liebig and others, to 
be the means by which oxygen is carried throughout the circu- 
lation, and brought to act on the various textures. Their pro- 
portion varies considerably in health; it may be stated generally 
at 120 or 130 in 1000 of blood. 

184. Excess of the red particles mighl therefore be expected 
to cause a general excitement of the vital properties of the body, 
(§183.) Accordingly, Lecanu found that they exist in larger 
proportion in persons of sanguine temperament (§38) than in 
others, and more in males than in females. Andral and Gavarret 
detected an excess in the early stage of inflammations and fevers, 
especially eruptive fevers, as measles and scarlatina. [?] In san- 
guineous plethora, also, and in hemorrhagic diseases before 
much blood is lost, they were in excess, in some instances rising 
to 185 in 1000 of blood. The obvious sign of the abundance of 
red particles is the florid colour apparent in the lips, cheeks, gums, 
and other vascular parts; the deep-blue colour of the superficial 
veins; and the fine deep crimson which a thin film of blood gives 
on a white plate. The functions, animal heat, and muscular irri- 
tability are in an elevated state, bordering on or passing into 
febrile excitement. 

[In thirty-five venesections of plethoric individuals, the mean 
of the red corpuscles was 141; maximum, 154; minimum, 131. 
(Andral.)— C] 

* Ann. de Chimie et Physique, Juillet, 1842. 



ELEMENTARY CHANGES OF THE BLOOD — RED PARTICLES. 103 

185. The red particles are defective in persons of the lymph- 
atic or leucophlegmatic temperament, (§ 40;) after great losses 
of blood, (artificial or from disease;) in chlorosis, and in other 
anaemic states, as those connected with advanced stages of can- 
cer, diabetes, scurvy, and other cachectic diseases; in scrofulous 
and tuberculous diseases; in the latter periods of fevers, and after 
severe inflammations; in granular degeneration of the kidney, 
and other organic diseases attended with dropsy; in diseases of 
the spleen, and others of malarious origin, (§85.) In extreme 
cases of chlorosis, the proportion of the red particles was found, 
by Andral, reduced to 28 in 1000 of blood. 

The signs of the defect are, paleness of parts naturally coloured 
with blood, pallid or sallow hue of the skin, pink colour of super- 
ficial veins, and a pinkish or light purplish hue of a film of blood 
on a white plate. The symptoms of such a condition are those 
which will be more fully described under the head of anaemia; a 
weak state of the functions generally, of circulation, calorification, 
digestion, and nutrition, constituting their summary. 

[The maximum attained by the red corpuscles in health is 140, 
whilst the minimum is 110 in 1000. Force and strength of con- 
stitution is the condition of the economy favourable to the former, 
and feebleness, congenital or acquired, to the latter. Sanguine 
losses, and deprivation of food, produce, as a constant effect, dimi- 
nution in the red corpuscles, whilst the fibrin, as. we shall see, is 
less constantly and necessarily influenced by these causes. Dimi- 
nution in the quantity of the red corpuscles may exist as an inde- 
pendent morbid state, or may supervene as an epiphenomenon in 
other diseases. In 24 cases of confirmed spontaneous anaemia, 
the mean of the red corpuscles was 64, (Andral.) In the cachectic 
condition resulting from the poison of lead, so well described by 
Dr. Tanquerel, the red corpuscles fell to the same mean as in 
spontaneous anaemia, whilst the other materials of the blood re- 
mained unaltered. Certain modifications in the organism may 
influence the blood, and diminish, the quantity of the red corpus- 
cles. This occurs ordinarily in pregnancy. In the neuroses, the 
blood is remarkably poor in red corpuscles; in phthisis, there is 
diminution of this constituent, as well as in all chronic organic 
diseases. — C] 

186. The red particles are evidently altered in some diseases, 
the colouring matter being much darker than usual, as in the 
worst forms of scurvy, in which the blood is said, by Mead, to be 
changed to a dark brown or green colour: in the Walchcren and 
other malignant fevers it has been described as pitchy black. Some 
change, seems to occur in congestive typhoid fevers, in which the 
blood-vessels become stained or dyed of a deep claret colour: this 
imbibition implies an unnatural solution of the red particles. Pro- 



104 ULTIMATE ELEMENTS OF DISEASE. 

bably the occurrence of petechias and ecchymosed patches in these 
diseases is partly dependent on a similar change. The readiness 
with which the textures become stained in scorbutic subjects, and 
in secondary syphilis, seems to indicate an alteration in the colour- 
ing matter; all inflammations and ecchymoses in the skin being 
followed by livid, purple, or copper-coloured stains. The black 
matter of melanosis seems to be the colouring part of the blood in 
an altered state: this is certainly true of the spurious melanosis 
of the intestines. 

187. Besides changes in colour, the red particles may probably 
be subject to. alterations in their form, size, and other properties 
in connection with the medium in which they are placed. It was 
first observed by Hewson, that pure water causes them to swell, 
become globular, and burst; whilst saline solutions, containing 
more salts than serum does, make them shrink in size. These 
changes are now generally understood to arise from endosmosis 
and exosmosis: the saline matter drawing the water into or out 
of the little cell which constitutes the red particle. It has not 
been ascertained, but it is highly probable that similar changes 
may take place in the living body, from circumstances which 
greatly alter the proportion of saline matter and water in the 
blood. May such change contribute to produce the serious symp- 
toms, and even sudden death, which have ensued on drinking a 
large quantity of water after great exertion? Has it aught to do 
with the reaction and irregular excitement sometimes occurring 
after excessive losses of blood? Or with the symptoms of suffering 
which animals manifest at the instant of injecting water into their 
veins? 

[In two cases of chlorosis, Andral found the red corpuscles 
smaller than usual, many of them altered in form, appearing in 
the field of the microscope as if broken into fragments. A young 
girl whose blood presented this appearance, became, after two 
months of appropriate treatment, plethoric; and, at this interval, 
on the globules being examined, they were found in a perfectly 
healthy state. In an epidemic typhus which prevailed in different 
districts of Italy in 1841, M. Renzi, of Naples, states, that the 
red corpuscles were readily freed of their colouring matter, seemed 
to have lost their central nucleus, and were altogether less com- 
pact and solid than naturally. — C] 

188. The change of the blood from dark to florid, on the addi- 
tion of saline matter, appears to depend on the increased density 
and opacity given to the red particles or their nuclei, and to the 
colourless globules, whereby they reflect light more abundantly 
and are also rendered less transparent.* Probably the action of 
oxygen in reddening venous blood is of a similar character. 

* Medical Gazette, Sept. 1835. 



ELEMENTARY CHANGES IN THE BLOOD RED PARTICLES. 105 

189. The red particles are distinct structures, living cells, (pro- 
bably nucleated,) although isolated and floating in a lifeless fluid. 
Like other nucleated cells, they probably possess the power of 
secretion and reproduction; but the office and mode of these have 
not been ascertained; and we can therefore say nothing of their 
modifications. It has been conjectured that they have other vital 
properties, such as spontaneous motion, and attractions and re- 
pulsions; but there are no unequivocal facts in support of such 
notions. The motions described by Treviranus, Schultz, and 
others, may be accounted for on purely physical principles. It is 
said, that a systolic and diastolic movement in blood particles has 
lately been observed, by Dr. Martin Barry, in the fallopian tube 
of a recently impregnated rabbit; but this needs confirmation. 

190. Mr. Wharton Jones has described changes in recently 
drawn blood, which he considers to arise from peculiar attractions 
subsisting between the particles.* Hewson, Prevost, Dumas, and 
others, remarked that red particles of new drawn blood cohere 
together in piles or rouleaus. Mr. W. Jones adds, that this cohe- 
sion in healthy blood is temporary only; and that, in a few seconds, 
the discs may be seen loose and confused; but in blood drawn 
from a person affected with inflammation, the cohesion takes 
place earlier, is more firm, and lasts longer than usual; and he 
considers this the chief cause of the separation of the red particles 
from the fibrin, which leads to the formation of the buffy coat. 
We shall notice the relation of this phenomenon to the buffy coat 
under the head of fibrin; but of the cohesion of the red particles 
we would remark, that it is not certain that it is more than one of 
mechanical aggregation induced by change in the relative dilution 
of the liquor sanguinis, or serum, without and within the blood 
corpuscle. The momentary exposure of so thin a film of blood 
to the air causes evaporation, which affects the serum before it 
can reach the interior of the blood particles. At this time they 
cohere; but the exosmosis proceeding from the individual parti- 
cles again detaches them from each other. But, without dwell- 
ing on this or the equally hypothetical notion that the cohesion 
is due to a vital attraction, it is not unimportant to observe this 
property, and the variety which is presented in inflammatory 
disease. But Mr. W. Jones is premature in assuming that a 
similar aggregation of the blood corpuscles occurs within the 
blood-vessels, and is the cause of obstruction in the capillaries in 
inflammation and other cases of impeded circulation. No such 
cohesion is seen in the large vessels of a frog's web, when the 
million of the blood is arrested by pressure on a vein; arid although 
the blood does coagulate in some of the vessels of an inflamed 

• British and Foreign Medical Review, Oct. 1842. 



106 ULTIMATE ELEMENTS OF DISEASE. 

part, this will hereafter be shown to begin with the colourless, 
rather than with the red particles. (See Inflammation.) 

191. Our inquiries as to the pathological causes of changes in 
quantity and quality of the red particles are baffled by our igno- 
rance as to the origin of these particles. The most plausible 
hypothesis is that advocated by Dr. Martin Barry, that they re- 
produce themselves. This does not altogether supersede the older 
notion that the lungs and the spleen may be the chief seats of 
their formation, nor that of Mr. Gulliver, that some may be 
formed from the globules of chyle. Certain it is that in serious 
and long continued diseases of the lungs or spleen, their quantity 
is remarkably diminished. But the same diminution is still more 
remarkable in chlorosis without any visceral disease. 

192. Remedied agents. — Excess of the red particles may be 
speedily removed by blood-letting, which reduces these much 
more than the other constituents of the blood. Low or vegetable 
diet, and the antiphlogistic regimen generally, produce a similar 
effect more tardily. It is not certain whether any hiedicines 
directly act in a similar way; but probably the continued use of 
mercury, colchicum and other medicines which largely increase 
the excretions, (§ 173,) ultimately reduce this element. The re- 
markable pallidity which accompanies the occurrence of extensive 
suppuration would also point to the formation of pus as a means 
of diminishing the red particles, which means may be used artifi- 
cially in the form of setons and suppurating counter-irritants. 

193. To promote the increase of the red particles, where de- 
fective, we might expect nourishing food, especially meat, ex- 
posure to invigorating air and light, with tonics generally, to be 
the proper means. But without experience we could not have 
anticipated that medicines containing iron should possess such 
remarkable efficacy in relation to this element of disease. In 
many cases of chlorosis, under the use of any suitable prepara- 
tion of iron, the complexion will change from waxy to ruddy, in 
three or four weeks' time. This subject will again come under 
our consideration in connection with anesmia. 

It has been supposed by Dr. Stevens that saline medicines have 
great power in restoring to their natural condition the red par- 
ticles which are changed in typhoid and malignant remittent 
fevers, (§ 186;) but if these remedies have any power in such 
maladies, it is very doubtful how much is to be ascribed to this 
mode of action. 



ELEMENTARY CHANGES IN THE BLOOD FIBRIN. 107 

SECTION VIII. 



194. The trifling difference in composition between fibrin and 
albumen (a minute addition of sulphur in the first) would scarcely 
distinguish them; but the self-coagulating property of fibrin is 
that which makes the distinction obvious, and most important in 
pathology.* Being the part which causes the coagulation of the 
blood, with all the varieties which that process exhibits; being 
the part which constitutes the buffy coat and coagulable lymph; 
and being probably the material by which textures are chiefly 
nourished and repaired, its changes must constitute an important 
element of disease. Although probably not so immediately con- 
cerned as the red particles in maintaining the vital processes of 
respiration, circulation, and innervation, it is yet a representative 
of the active state of these processes, and of the nutritive and 
reparative function; and it therefore exists in larger proportion in 
arterial than in venous blood. It is deficient in new-born ani- 
mals, but abundant in children and in persons who have been 
well fed, and are in robust health. The average proportion in 
health is three in one thousand of blood. (Andral.) 

[In some instances the fibrin may reach 4, or descend as low 
as 2 in 1000, without indication of disease. But it must be 
borne in mind that these maxima and minima are very rarely 
compatible with perfect health, and are to be regarded rather as 
belonging to idiosyncrasies. — C] 

195. An excess of fibrin, and of the colourless or lymph- 
globules, exists in inflammatory diseases, especially those of a 
sthenic character, and acute rheumatism. In some cases, MM. 
Andral and Gavarret found it as high as ten per thousand. The 
proportion of fibrin is also increased during the latter months of 

* [From the recent analyses of MM. Dumas and Cahours it would appear to 
be positively determined that fibrin, so far as regards the four elements — carbon, 
azote, oxygen, and hydrogen — instead of being identical with albumen, very 
essentially differs from it. The proportion of carbon, according to these chemists, 
is -7 per cent, less in fibrin than in albumen, whilst the proportion of azote is -8 
to -9 per cent. more. A correct idea of the elementary composition of fibrin may 
be formed, if we consider it as a combination of casein, or albumen, and ammonia. 
The same observers have found a vegetable fibrin equally distinct fromvege- 
table albumen. These analyses were conducted on a much larger scale, and a 
much clo er agreement was obtained than by any previous observer; a satisfac- 
tory evidence of the accuracy of the methods employed. This view of the 
chemical composition of fibrin and albumen derives additional veighl when wc 
consider the difference in their physiological properties, which is still better 
L— -C.J 



108 ULTIMATE ELEMENTS OP DISEASE. 

pregnancy.* These facts have been long known; but in addition 
to these, MM. Andral and Gavarret found an excess of fibrin 
in tuberculous diseases, in which we have noticed there is a 
defect of red particles, (§ 185.) Mr. Gulliver has observed the 
increase of white globules in blood drawn in inflammation; 
and I have noticed tins as occurring in the vessels. (See In- 
flammation.) 

196. Deficiency of fibrin is of frequent occurrence in many dis- 
eases and temporary conditions bordering on disease. Its sign is 
fluidity or imperfect coagulation of the blood when drawn. As 
venous blood contains less fibrin than arterial, so the quantity is 
absolutely diminished when the blood is more venous than usual, 
as in cases of asphyxia or impeded breathing; and in those of 
cyanosis, in which the venous blood becomes mixed with the 
arterial through an unnatural opening.! Excessive bodily fatigue 
and want of sleep expend the fibrin: hence the blood remains 
fluid in animals hunted to death, (§65.) It was stated by John 
Hunter that the same thing is observed in animals killed by 
lightning; but this is not always the case. In many instances 
the blood is found fluid in cases of death from poisoning and 
other sudden causes. In some of these the absence of fibrin 
may be attributed to the impeded respiration which is the im- 
mediate cause of death, as in some cases of death from hydro- 
cyanic acid, opium, strychnia, apoplexy, dividing the pneumo- 
gastric, (Dupuy,) &c. There is, however, some uncertainty about 
these facts. (See Mr. Blake's experiments mentioned further 
on.) But in others, as in poisoning with arsenic, sulphuretted 
hydrogen, and some other pernicious agents, the fluid state of the 
blood must be ascribed to a more direct operation on the blood 
itself. So likewise in adynamic fevers, which arise from a pecu- 
liar poison, the fluidity or imperfect coagulation of the blood 
is one of the most remarkable conditions, and seems to be a chief 
cause of the hemorrhages, petechias, and v ibices, which some- 
times occur in these fevers. In a case of very low typhoid fever, 
Andral found the proportion below one in one thousand. The 
artificial imitations of these fevers produced in dogs inoculated 
with various morbid or putrid matters, or confined over their ex- 
halations, in the experiments of Gaspard, Majendie, Gendrin, 
Leuret, and Hamon, exhibited a similar absence of fibrin in the 
blood, (§ 194.) 

The addition of some neutral and alkaline salts to the blood 

* In domestic animals the fibrin is diminished before, and increased after, par- 
turition. (Ann. de China. 1842.) 

f Poor food, or that defective in protein principles, lowers the quantity of 
fibrin, (§ 63.) 



ELEMENTARY CHANGES IN THE BLOOD FIBRIN. 109 

out of the body will diminish its coagulating property; and it 
has been stated that subsisting on salted food will produce a dis- 
solved or non-fibrinous state of the blood : during life; but this 
statement does not appear to be founded on any well ascertained 
facts, and is perhaps connected with the notions that salt food is 
the cause of sea scurvy, (§ 63,) and that the blood does not coa- 
gulate in this disease, both of which are erroneous. (Sea Lib. 
of Pract. Med., Art. Scurvy, by Dr. G. Budd.) 

197. Besides the sign already mentioned, permanent fluidity 
or little coagulation of the blood when drawn, a defect of fibrin 
causes a tendency to haemorrhages, generally of the asthenic 
kind, and to an unmanageable oozing of blood from any acci- 
dental wound or breach of texture. In the same cases, too, 
wounds do not readily heal, nor fractures unite. In fact, the 
plastic or reparative process is defective for want of its material, 
(§ 194;) and for a similar reason, the nutrition of textures which 
consist chiefly of fibrin, such as muscle, is ill maintained. 

198. Majendie found that animals, from whose blood fibrin 
had been abstracted, were affected with congestions and effusions 
in the lungs, brain, and other organs, which he ascribes to a cause 
supposed by M. Poisseuille to be a general physical fact; that 
very thin fluids pass with greater difficulty through capillary 
tubes than those of somewhat greater spissitude. But his ex- 
periments were too rude and his deductions too hasty to merit 
confidence; and the obstructions and congestions alluded to 
might be equally due to the cohesion of colourless or blood 
particles, or even to little clots of fibrin left by the coarse process 
employed. 

There can, however, be no doubt that a certain spissitude in 
the blood is favourable to its transit through the hydraulic appa- 
ratus of the circulation; and that when this is deficient, various 
irregularities in the distribution of the blood may occur. Some 
of these will be mentioned under the head of ansemia: but I may 
mention here that thin blood is easily thrown into sonorous 
vibration, and various unnatural sounds or murmurs in the heart, 
arteries, and veins, may be thus produced. As these are some- 
times met with in cases in which the complexion does not indi- 
cate a deficiency of red particles, and they are sometimes absent 
in the most pallid subjects, I am inclined to connect them as 
much with defect of the fibrin and albumen as with that of the 
red particles of the blood. 

199. .alterations in the quality of the fibrin introduce to our 
notice the important morbid appearances presented by the buft'y 
coat and contraction of the clot of blood. 

As the consolidation of the fibrin is the cause of the coasmla- 
10 6 



110 ULTIMATE ELEMENTS OF DISEASE. 

tion of the blood, so differences in the coagulum represent varia- 
tions in the properties of the fibrin. 

200. A large firm coagulum indicates an abundance of fibrin, 
as well as of red particles, and is commonly presented by healthy 
blood. A loose coagulum implies a deficiency of fibrin. A 
small firm clot betokens a proportion of fibrin exceeding that of 
the red particles; but the smallness of the clot points to another 
property of the fibrin, which is in excess, that of contraction 
during and after its consolidation. Again: in this case as in 
others, the upper part of the clot is commonly more contracted 
than the lower portion: it is also firmer and contains more fibrin, 
whilst the lower abounds more in red particles. Here there is 
evidently a tendency to a separation of the red particles from the 
fibrin. In other cases, again, the separation is to some extent 
complete, the red particles subsiding, whilst the fibrin rises to the 
surface, and on coagulating forms at the top of the clot a layer of 
a light yellow or buff colour, commonly known by the name of 
the buffi j coat. 

201. It may be inferred, then, that besides self -con filiation, 
(§ 194,) fibrin possesses a property of contraction, and another 
of separation from the red particles; and these properties are 
presented in different degrees in different states of the system. 
Let us consider these properties, first separately, afterwards in 
combination. 

202. Self-coagulation is generally retarded in inflammatory 
discuses, and in other cases in which the fibrin is abundant, 
(§ 11)5,) its amount is indicated by the firmness and size of the 
clot. Other circumstances, however, may make the coagulation 
slow, as warmth and seclusion from the air; whereas cooling 
quickly, and exposure to the air, as when the blood trickles from 
the vein, or is drawn into a shallow vessel, hasten the coagula- 
tion. The addition of some saline matters, such as common salt, 
carbonate or sulphate of soda, also retards the coagulation of the 
blood. 

203. The contraction of the clot evidently depends on the 
attraction of the particles of fibrin for one another after the coagu- 
lation has begun. By the contraction, the red particles entangled 
in the fibrin are also drawn together whilst a portion of the serum 
is squeezed out. The more slow the coagulation is, generally 
the greater will be the contraction. Hence the upper surface of 
the clot is often formed more quickly, (§ 202,) and is therefore 
larger than that below, whilst the middle portions of this large 
upper film being drawn downwards by the contraction of that 
below, cause the concave or cupped appearance in the clot, so 
commonly seen in buffed blood, (§ 200.) By drawing blood 
slowly, or in a shallow vessel, the coagulum is speedily formed in 



ELEMENTARY CHANGES IN THE BE00D FIBRIN. Ill 

all parts, and adhering to the sides it is not cupped, (§ 202.) The 
contraction and cupping of the clot being due to the fibrin, might 
be expected to be in proportion to its quantity; and this is the 
case in inflammatory diseases. But there is also great contraction 
and often cupping in chlorosis and some analogous states, in 
which the fibrin is not absolutely increased; but the red particles 
being much diminished, the contractile property of the fibrin is 
not impeded. For a similar reason the contraction is greatest 
where the quantity of fibrin is greatest, and most completely 
separated from the red particles. On the other hand, there is 
little or no contraction where the red particles are in great 
abundance, as in sanguineous plethora, (§ 184,) or where the 
aggregation of the fibrin is impaired by the addition of saline 
matter, (§196.) 

204. The separation of the fibrin from the red particles, (§ 200,) 
as exhibited in the buffy coat, has attracted much attention, and 
has been ascribed to various causes. As the fibrin always rises 
to the surface, and the red particles sink, it is obvious that a chief 
cause of the separation is the greater weight of the latter, which 
subside entirely from the upper layer of fibrin before it has time 
to coagulate. Now, this subsidence will be favoured by three 
circumstances — 1, the tardy coagulation of the fibrin giving more 
time for the separation; 2, increased specific gravity of the red 
particles; 3, diminished spissitude of the liquor sanguinis. Now 
all these three conditions may be fulfilled by adding a little salt 
to healthy blood as it flows from the vein; and this addition 
really does produce a separation of the fibrin; but the fibrin thus 
rising to the surface has neither the contraction (§ 203) nor the 
firmness of the inflammatory buff, but is gelatinous, like size, and 
rather resembles the sizy blood sometimes exhibited in scurvy 
and diabetes. Further: although blood in inflammation is gene- 
rally slow to coagulate, it is not so always; and in extreme cases, 
as in acute rheumatism, the buff appears even where the coagu- 
lation is speedy, and, according to Schroeder Van der Kolk, is 
seen in patches and thin films where gravitation would not have 
promoted the separation.* There must, then, be some other 
cause for the formation of the buffy coat besides those above 
mentioned. The great firmness and contraction of the surface 
of inflamed blood may be ascribed to the increased proportion of 
fibrin, which is constantly present. 

[Whenever there is excess of fibrin, whether relative or abso- 
lute, and the coagulation of the fibrin does not occur too rapidly, 
it will accumulate alone on the surface of the clot, and form a 
buffy coat. Thus the blood of anaemia is buffed, whilst that of 

* Alison's Outlines of Physiology, p. 89. 



112 ULTIMATE ELEMENTS OF DISEASE. 

plethora is not; the huff in the blood of pregnant women is 
owing to the excess of fibrin relatively to the globules. This 
explains too the buff in the blood drawn from horses, where there 
is predominance of fibrin over the red corpuscules. — C] 

205. Dr. Alison considers the separation of the fibrin in in- 
flammation to be due to a vital repulsion between the fibrin and 
the colouring matter.* Mr. Wharton Jones thinks that the tend- 
ency to separate may be entirely explained by the increased 
aggregation (before noticed, § 190,) which he observed in the red 
particles of inflammatory blood: these, by their cohesion, act like 
a sponge, contracting and squeezing out the fibrin from between 
them before it coagulates. (Brit, and For. Med. Rev., Oct. 1842, 
p. 592.) I do not consider this comparison a just one; for, so far 
as I have seen, the cohesion of the red corpuscles is not in an 
entire mass, but only in separate piles or rouleaux: these would 
facilitate the separation, not only by contractile aggregation, but 
also by sinking through the liquid fibrin more quickly than sepa- 
rate particles would; just as bits of chalk fall to the bottom of 
water instead of remaining long suspended, as they would do in 
fine powder. The fact that the red particles do aggregate more 
completely and for a longer time in inflamed than in healthy 
blood, is valuable, because it furnishes us with a microscopic test 
of the inflammatory condition of the blood, applicable, as Mr. W. 
Jones remarks, to a minute drop of blood drawn from a prick of 
the finger.t 

The subjoined sections of the different appearances of coagu- 
lated blood may assist the student to understand their nature and 
causes. 

206. This presents uniform coagulation 
with little contraction. If the clot is mode- 
rately firm, the blood is rich in fibrin and 
in red particles, as from persons in robust 
health. If the clot is very soft and uniform, 
the fibrin is deficient, as in typhoid fevers, 
exhaustion from exertion, &c. If the clot 
is very soft, especially at the bottom, and the top covered with a 
soft sizy film, the coagulation lias been slow, as in scurvy and in 
slight inflammations occurring in typhoid fevers. 

* Dr. Carpenter suggests that increased attraction of the red particles for 
each other, and of the molecules of fihrin for each other, would, more consist- 
ently with analogy, produce the same effeet. (Pr. of Human Physiology, [Am. 
Ed. p. 430.]) 

-j- [See Carpenter's Principles of Human Physiology, Am. Ed. Note by the 
Editor, p. 430, 431, and Ed. Med. and Surg. Journal, Oct. 1813.] 





ELEMENTARY CHANGES IN THE BLOOD FIBRIN. 113 

207. Uniform coagulation with great con- 
r -""^ I traction, which takes place where the pro- 
\ clot J J p 0r tion offibrin much predominates over that 

' of the red particles, as in chlorosis. The 
relative as well as the absolute quantity of 
the fibrin is indicated by the firmness of the 
clot. This appearance, with a bufTy surface, 

is often exhibited by blood drawn in inflammation in ansemic 

subjects or in advanced stages, and in phthisis. 

208. Blood highly buffed and cupped, as 
in acute rheumatism and other severe in- 
flammations. The fibrin here presents in a 
high degree its properties of separation, co- 
agulation, and contraction; having almost 
abandoned the red particles, which are loose 
at the bottom of the vessel, and having risen 

to the surface, where it appears as a tough, contracted, concave, 
and buffy clot. 

209. To exhibit the true properties of the blood in coagulation, 
it should be drawn by a full stream into a deep or globe-shaped 
basin or cup, previously warmed, and kept covered over until the 
coagulation is complete. These precautions retard the coagula- 
tion,' and favour the separation and contraction of the fibrin. On 
the other hand, if the blood merely trickles from the vein, as when 
the orifice is small or the patient faint; or when the receiving ves- 
sel is shallow and cold, the blood congeals at once, and prevents 
the appearance of the buffy coat, (§ 202.) This is one reason 
why blood drawn at one blood-letting often exhibits a different 
appearance in different vessels. 

210. We have before noticed that the fibrin of the blood may 
be speedily exhausted by violent muscular exertion, and by se- 
rious impediment to the respiration, (§ 196.) These, and the fact 
that it exists in larger proportion in arterial than in venous blood, 
seem to point out that it is expended in the nourishment of the 
muscular and other textures, and is renewed through the agency 
of respiration. It might be supposed that inflammation increases 
its quantity by accelerating the circulation and respiration with- 
out adequate expenditure; but although this may be a contribut- 
ing cause, particularly in acute rheumatism, it is not sufficient, 
for the quantity of fibrin is not proportioned to the frequency of 
the pulse or respiration; it is often much increased before these 
are materially affected, and in idiopathic fevers it is diminished, 
althouirli tin- breathing and pulse are commonly accelerated. In 
fact, various circumstances, to be detailed hereafter, render it pro- 
bable that the increase of fibrin during inflammation has its ori- 
gin in the vessels of the inflamed part. Then; is little doubt that 

10* 



114 ULTIMATE ELEMENTS OF DISEASE. 

fibrin is elaborated from the albumen of the serum, but whether 
through the agency of the red particles, as secreting cells, as sup- 
posed by Wagner, Henle, and others, or by that of nucleated cor- 
puscles in the blood and lining the vessels of textures, is uncertain; 
but the former opinion seems the most probable. 

211. Fibrin, or the buffy coat of the blood, is also the material 
of which new membranes and cicatrices are formed, constituting 
the coa guluble lymph, which is the plasma or basis of the con- 
structive or reparative process. But in its capacity for this pro- 
cess, fibrin exhibits some varieties. The plasma with which old 
textures are nourished, and new ones formed, is eiiplastic in a 
healthy state, having a capacity of life, and may become organ- 
ized in a high degree, as in false membranes resulting from acute 
inflammation in a healthy subject. But in many instances this 
capacity is degraded, and the nutritive material is caco-plastic, 
susceptible of only a low degree of organization, as in the indu- 
rations resulting from low or chronic inflammation, fibrocarti- 
lage, cirrhosis, gray tubercle, &c, or it is aplastic, not organizable 
at all, as in pus, curdy matter, yellow tubercle, &c. It is a point 
of great importance, that the quantity of fibrin in the blood, and 
the facility with which it may be effused, are by no means in 
proportion to its plasticity, or capacity to become organized; thus 
it is abundant in the blood, and freely effused in the inflamma- 
tions of scrofulous or tuberculous subjects, although the products 
of these inflammations and of nutrition are commonly caco-plastic 
or aplastic. It is interesting to observe that in these cases also 
the red particles are defective in number. 

212. The rudiments of organization may be seen in the buffy 
coat in the form of nucleated globules or cellgerms, scattered 
among bundles of minute fibres, crossing each other in various 
ways.* 

[The observations of MM. Andral and Gavarret on this point 
are highly interesting. They took the blood of a patient labour- 
ing under pneumonia, and as soon as the yellow opaline liquid 
appeared above the mass of red corpuscles, a drop was placed 
under the microscope. Besides the red corpuscles, the field of 
the microscope was filled with granular corpuscles, (lymph cor- 
puscles.) When the buffed coat was nearly solidified, it was re- 
examined; a great number of fibres of extreme tenuity were now 
seen, resembling very long and fine threads, interlaced with each 
other in various directions, with intervening spaces more or less 
large. The fibres, finally, assumed the appearance of a genuine 
net-work. At first they were few, and scarcely visible, but be- 

* Gulliver's Notes to Gerber's General Anatomy, App. p. 19. 



ELEMENTARY CHANGES IN THE BLOOD — FIBRIN. 115 

came more and more numerous, and soon filled the entire field 
of the microscope. In proportion as they multiplied they formed 
superimposed planes, and the appearance of a simple net-work 
was replaced by that of felt, but the fundamental form remained 
always reticular. As the solidification of the clot increased the 
interlaced fibres diminished, and it finally became a confused 
mass. Repeated experiments gave the same results. 

If the sero-fibrous fluid obtained from the globules by treating 
the blood with the sulphate of soda be examined under the mi- 
croscope, you will observe the same reticular arrangement in the 
flocculi which speedily appear in the liquid. There is no doubt 
that several of the elementary tissues of the body are formed in 
this way. (550.) C] 

It is probable that the globules are identical with the colourless 
or lymph globules of the blood, which are pretty good represent- 
atives of the proportion of fibrin in the blood. In the frog, the 
white globule in the blood and the cellgerm of lymph seem iden- 
tical; but Mr. Gulliver observes, that in mammalia the latter is 
considerably smaller in size: it is probably younger. 

213. The coagulation of fibrin is promoted by the contact and 
motion of a rough solid: thus by stirring fresh-drawn blood with 
a stick, the fibrin adheres in shreds to the stick. The same pro- 
perty is exhibited within the body in the deposition of lymph 
(vegetations) on rough surfaces within the heart and great ves- 
sels, and it is probable that the fibrinous concretions called polypi, 
which are found after death in the heart, are formed on its irre- 
gular surfaces, as its failing motions cause agitation more than 
propulsion of the blood. 

Remedial agents. 

214. Excess of fibrin (§ 195) is less directly reduced by blood- 
letting and low diet, than is excess of the red particles; yet these 
are the chief means of lowering the quantity of fibrin in the blood. 
It would probably be found that purgatives, and other remedies 
which increase much the more solid secretions, diminish the 
fibrin. A similar property has been ascribed to mercury, to 
alkaline salts, to iodine, and to antimony. I know of no positive 
facts in support of this notion; but it is favoured by some ana- 
logies, and seems well worthy of experimental investigation. 
The operation of salts and alkalies in this way was probably 
suggested by their property of dissolving fibrin out of the body.* 

• My friend Mr. Blake has made many experiments of injecting various saline 
and other fluids into the veins, and he has furnished me with a summary of their 
effects on the blood, as found after death. 

The blood was found coagulated after the injection of the following matters: — 
Liquor potasssc (firmly); carbonate of potass (firmly); nitrate of potass (firmly; 



116 ULTIMATE ELEMENTS OP DISEASE. 

215. According to the views of Liebig, subsisting chiefly on 
saccharine, amylaceous, or gelatinous articles of food, must reduce 
the fibrin and albumen of the blood; and such food is found by 
experience to be the best in inflammatory diseases, in which ex- 
cess of fibrin is a chief element. Is the reputed efficacy of the 
"cure de raisins," in tuberculous disease, connected with the ab- 
sence of protein compounds in the food? Bodily exercise reduces 
the fibrin, and may be advantageously employed with this view 
in sthenic plethora; but is not admissible in inflammatory dis- 
eases. Neither can we suggest any practicable mode of lessen- 
ing the fibrin by lowering the function of respiration, on which 
its supply seems to depend, unless narcotics, which impair many 
organic functions, have some action of this kind. The known 
utility of opium, aconite, &c, in rheumatism and low forms of 
inflammation, in which excess of fibrin is a constant element, 
makes this matter deserving of some research. 

216. Deficiency of fibrin (§ 196) is to be remedied by assist- 
ing those functions on which its supply depends, particularly 
those of digestion, respiration, and assimilation, and by avoiding 
its expenditure in too much exercise and other exhausting pro- 
cesses. If the digestive organs will bear them, meat, eggs, bread, 
and other articles of diet abounding in the protein compounds, 
should be taken. The digestive and assimilative functions may 
be assisted by stimulants, bitters, cminine, and the mineral acids, 
which, from their power in stopping passive haemorrhage, and in 
augmenting the muscular strength, seem to promote the forma- 
tion of fibrin more directly than by their mere operation on the 
digestive organs. To improve the function of respiration, besides 
attempts to remove or diminish any disease from which it may 
suffer, the free access of pure cool air to the lungs should be se- 
cured. The injurious effect of exertion is exemplified in the re- 
lapses which it often induces in continued fever, in which defect 
of fibrin in the blood is a chief element. Fatigue of every kind, 
and wakefulness, should be carefully avoided, and sleep obtained 
by narcotics, if it do not come naturally. In case of any defi- 

blood scarlet); nitrate of soda; nitrate of ammonia; nitrate of lime; nitrate of 
baryta; chloride of calcium; chloride of barium, chloride of strontium; sulphate 
of magnesia; sulphate of copper; acetate of lead; arsenite of potass; nitric acid 
(strongly); narcotin (firmly); tobacco; strychnia (moderately); conium; hydro- 
cyanic acid; euphorbium; and water in quantity. 

The blood was not coagulated, or imperfectly so, after injection of caustic 
soda, carbonate of soda, sulphate of soda, ammonia, nitrate of silver, sulphate of 
zinc, sulphate of iron, phosphoric acid, arsenic acid, arsenious acid, oxalic acid, 
infusion of galls, of digitalis, alloxan. 

Some of these results are different from what might have been expected; in- 
stance the decided coagulation with potass and its salts, especially nitre, and the 
fluidity with nitrate of silver, sulphate of zinc, infusion of nutgalls, which have 
been commonly supposed to possess a coagulating property. 



ELEMENTARY CHANGES IN THE BLOOD FIBRIN. 117 

ciency of fibrin from the presence of a febriferous or putrescent 
poison in the system, it is not to be expected that fibrinous food, 
rest, or any other means, can remove the deficiency, so long as 
the poison remains in active operation. This poison, by its septic 
or analogous influence, interferes with the vital process by which 
the fibrin is formed. But no sooner does the influence of the 
poison subside, as evidenced by improvement in the symptoms, 
than the quantity of fibrin increases; and this sooner than could 
be explained by any increase of nourishment taken. (Andral 
and Gavarret.) 

217. Very little is known of the power of remedies to correct 
changes in the quality of the fibrin of the blood. The increased 
properties of separation (§ 204) and contraction (§ 203) manifested 
by blood in inflammation, are reduced by blood-letting and other 
antiphlogistic remedies, even more constantly than the excessive 
proportion of fibrin is by the same means; but they seem to be 
soon reproduced if the inflammation continues. Thus, although 
the last cup drawn in blood-letting may exhibit none of the buffed 
and cupped appearance presented by the first cups, yet blood 
drawn a few hours after often shows as much as any taken be- 
fore. Knowing that this speedy recurrence of morbid properties 
in the blood depends on the influence of the local inflammation, 
we see the necessity of fully using local means, together with 
those calculated to operate on the system. 

218. Blood-letting and' other general antiphlogistic remedies, if 
they do not remove local inflammation, may render its products 
more injurious by lowering their plasticity, (§ 211,) and approxi- 
mating them to tuberculous and other aplastic deposits. Thus 
chronic inflammation continuing after the full application of the 
antiphlogistic treatment, almost surely tends to produce degene- 
rated changes of structure, over which remedial art has little 
power. In connection with this subject, therefore, we see how 
desirable it is that inflammations should be removed before they 
become chronic; and when there is a risk of their becoming so, 
it should be an indication to improve the condition of the blood 
by a tonic and nutritive plan, at the same time that local anti- 
phlogistic measures maybe necessary for the lingering inflam- 
mation. 

2 19. A similar tonic treatment is still more indicated in scro- 
fulous, chlorotic, and other cachectic states in which the fibrin, 
although less abundant than in inflammation, is yet copious in 
proportion to the scanty red particles, (§ 211.) Hence the lend- 
<n<y to the deposit of imperfect fibrin, even independently of 
inflammation; and besides means calculated to improve the nun 
incut functions and to raise the character of their product, it may 
I"' necessary to use remedies likely to keep the fibrin dissolved, 



118 ULTIMATE ELEMENTS OP DISEASE. 

and to prevent its deposit in its aplastic forms. Alkalies and 
iodide of potassium have some claims to these properties. 



SECTION IX. 

ALBUMEN AND OTHER ANIMAL PRINCIPLES DISSOLVED IN THE 

SERUM. 

220. These form a considerable constituent of the blood, 
amounting on an average to seventy-two per thousand in health. 
It is generally supposed that the albumen of the serum is chiefly 
useful as affording the material from which the plasma (fibrin) is 
elaborated; but it is by no means certain that some textures, such 
as those less highly organized, composed of albumen and gelatine, 
may not be formed at once from the constituents of the serum. 
The albumen is further useful in giving to the serum a consistency 
favourable for its circulation, and for suspending and preserving 
the red corpuscles, and in blandly sheathing the acrimony of the 
saline constituents. The quantity of albumen may be estimated 
by the specific gravity of the serum, which in healthy subjects 
averages at about 1030. 

[There is about 68 to 70 of pure albumen in 1000 parts of 
blood, independent of the organic and inorganic elements of the 
serum. — C.J 

221. Excess of albumen exists in most cases of inflammations 
and fevers, especially during their more active stages. Its in- 
crease is not, however, in proportion to that of the fibrin. Its 
relative proportion is much increased in epidemic cholera;- but 
this is rather due to the removal of the water of the blood. 
Albumen is the principle least affected in its proportions by dis- 
ease. Very poor living, long continued, extensive haemorrhages, 
and other drains on the system, will pretty surely reduce it in 
common with the other animal principles of the blood; but good 
living has less power in raising it above the natural standard. 

222. Deficiency of albumen in the blood is most remarkably 
met with in cases of albuminuria, or disease of the kidney with 
coagulable urine; and this deficiency precedes the diminution of 
the red particles, which takes place in the advanced stages of this 
disease. Dr. Bright found in a patient with albuminuria, the 
specific gravity of the serum as low as 1013. (Bright 's Re- 
ports, vol. i. p. So.) Dr. Babington found the specific gravity of 
the serum in a case of diabetes as low as 1024; in another 1027, 
although that of the blood was higher than usual, 10G1. In this 



ELEMENTARY CHANGES IN THE BLOOD OIL. 119 

case the serum was milky. (Cycl. of Anat., &c, Art. "Blood.") 
In their later researches, MM. Andral, Gavarret, and Delafond, 
discovered a remarkable diminution of the albumen in dropsical 
sheep affected with the rot, (a watery state of the blood, with 
distoma in the liver.) Sheep in a cachectic state, with deficiency 
of red particles, but without entozoa, were not dropsical, and in 
these the albumen was found undiminished. It is therefore most 
probable that the cases of cachexia, or anaemia, attended by 
dropsy, owe this concomitant to a defect of albumen in the blood. 
It is this principle chiefly that gives the blood liquor its spissitude, 
which renders it more fit to pass along the vessels, and prevents 
it from transuding through their walls. This deficiency of albu- 
men, therefore, seems to be a chief constituent of the dropsical 
diathesis. 



SECTION X. 



223. The oil or fatty matter in the blood sometimes is so much 
increased as to give a milky appearance to the serum; but it is 
not known with what pathological conditions this or other varia- 
tions in the fat of the blood may be connected. It has been ob- 
served to occur not only in fat subjects. Hewson noticed it in 
the blood of three plethoric individuals. Dr. Babington met 
with an extreme degree of it in a case of advanced diabetes. 
This physician states that he has found milky serum of low spe- 
cific gravity, indicating a defect of albumen; and he suggests 
that the fat might originate in a change in the albumen. This 
would not accord with the views of Liebig. The notion of 
Ilaller, that the milkiness of serum was caused by an admixture 
of chyle, does not seem exact; the whiteness of the latter being 
due to an infinity of minute molecules described by Mr. Gulliver. 
Under the more probable idea that milky serum derives its 
increase of fatty globules from absorption from fat textures, it 
should be met with during any rapid diminution of bulk of the 
body. 

224. The increase of fat in the textures is probably preceded 
and accompanied by its presence in excess in the blood; and the 
circumstances which promote obesity must operate through the 
composition of this fluid. Of these may be mentioned fat, sweet 
and farinaceous food in excess, without disorder of the digestive 
organs; full living, without exercise. Exercise tends especially 
to reduce the fat of the body; probably by causing its combustion 
in respiration, whilst muscular textures arc increased by the same 
influence. 



120 ULTIMATE ELEMENTS OF DISEASE. 



SECTION XI. 

SALINE MATTER. 

225. It is not known that the salts of the blood are augmented 
in any diseases. It has been surmised, that the thirst caused by- 
taking much salt or saline water is due to a febrile excitement 
which the salt in the blood induces. But this is by no means 
certain; for this thirst is not generally attended with increased 
heat of skin. There may be thirst without fever, although fever 
is often accompanied by thirst. 

226. Diminution of saline matter in the blood has been said, 
by Dr. Stevens, to take place in yellow fever and other pesti- 
lential diseases, and to cause so dark and grumous a state of the 
blood, that exposure to air will not, as usual, render it florid. 
This fact has been more distinctly ascertained by Dr. O'Shaugh- 
nessy, with regard to malignant cholera, in which the defect of 
saline matter and water seems to be the immediate cause of the 
obstructed circulation, lividity, and collapse, so remarkable in 
that terrible disease. Accordingly, Dr. Mackintosh found the 
blood extensively coagulated in the heart and large vessels. 
Hence the temporary efficacy of injection of saline solutions into 
the veins of cholera patients; it seemed at once to renew circula- 
tion, respiration, warmth, and other functions — life, in fact, to the 
patient — as if the saline solution were all the thing needed. But 
this defect of serum in the blood is only an effect of the excessive 
evacuations from the stomach and bowels; and if these go on, 
the good effect of saline injections is soon exhausted. 

227. The presence of a certain amount of saline matter is 
essential to the preservation of the red particles in their natural 
size and form, and probably, likewise, to the liquidity of the 
fibrin. There can be no doubt, therefore, that, in the extreme 
cases of cholera just mentioned, the blood coagulates in the ves- 
sels for want of saline matter, and the red particles become dis- 
solved and altered. The researches of Andral scarcely support 
the notion that similar changes take place in typhus fever, as 
supposed by Dr. Stevens. If saline medicines are useful in com- 
mon continued fevers, it is a question whether it is in this way, 
by supplying what is defective; it may rather be by augmenting 
deficient secretions, (§ 171,) and tending to remove or counteract 
septic influences present in the system, (§ 98, 105.) 



ELEMENTARY CHANGES IN THE BLOOD WATER. 121 



SECTION XII. 



228. It is obvious, from what has been already noticed, that 
the proportion of water in the blood increases as that of the ani- 
mal contents decreases. Thus, after extensive haemorrhages, and 
in chlorosis and other cachectic states attended with anaemia, the 
blood is more watery than usual. [In a woman who had suf- 
fered from abundant and repeated metorrhagias, the blood con- 
tained only in red corpuscles 21; in fibrin 18; in solid matters of 
the serum 61; whilst the water was raised to 915 in 1000. (An- 
dral). — C] The effect of this state of the blood is to cause a 
tendency to dropsical effusions and fluxes, besides the conse- 
quences which result from a deficiency of the other constituents 
of the blood. 

229. I have before suggested a question, (§ 187,) whether the 
serious functional disturbance sometimes following the ingestion 
of very large quantities of liquids, particularly after exertion, 
when absorption is active, may not in some degree arise from the 
too copious and sudden addition of water to the blood. Certainly 
temporary plethora, with palpitation, feeling of oppression or 
dyspnoea, often results from the too free ingurgitation of liquids, 
and is not removed until perspiration, or a free flow of urine, 
relieves the distended vessels. These symptoms are most dis- 
tinctly observed where some permanent disease of the organs of 
circulation or respiration incapacitates them for the increased 
task. Hence the aggravation of the symptoms of disease of the 
heart and lungs, by too much drink. The colliquative sweats 
in phthisis seem to arise from a similar cause, and may often be 
relieved by a judicious reduction in the quantity of liquid food. 

230. Deficiency of water in the blood is exemplified in epi- 
demic cholera, in which the specific gravity of the serum has 
been found as high as 1045 (Lecanu), which implies a reduction 
of nearly half the natural proportion of water. Some diminution 
probably takes place in other diseases, attended by profuse watery 
discharges, such as diarrhoea, diabetes, and excessive sweating. 
In these cases, the smallness of the pulse, and sometimes the 
shrunk appearance of the surface from the undistended state of 
the vessels, are signs of the diminished bulk of the circulating 
fluid; and thirst pretty constantly points out the mode which 
nature prompts to remedy the defect. In the same way, expo- 
sure to heat, especially if continued, and prolonged violent exor- 
cist:, expends the water of the blood, and causes the feeling of 

11 



122 ULTIMATE ELEMENTS OF DISEASE. 

thirst through which it may be restored. Long abstinence from 
liquids has a similar effect. 

It has been already mentioned, that the extraordinary decrease 
of the water of the blood which occurs in malignant cholera ren- 
ders the blood so thick, that it cannot circulate freely, and tins 
change is the chief cause of the cessation of the pulse, lividity, 
and other signs of obstructed circulation. No such effect is 
known to follow from any of the other causes of deficient water. 
The operation of heat and continued exertion is not simple, and 
therefore not referable to this principle only. Abstinence from 
liquids for two or three days induces languor, small and easily 
accelerated pulse, a somewhat pasty state of the mouth, and 
scantiness and turbidity of the urine, but little derangement of 
other functions. The digestive process, which might be expected 
to suffer, in some cases at least, shows no symptoms of disorder. 

231. We thus have means of increasing or reducing the water 
of the blood by increasing or diminishing the liquids drunk; 
and these expedients may be usefully employed in the cases 
above mentioned. But these expedients in their extremes also 
furnish us with therapeutic agents of more extensive power. 
Drinking large quantities of water may, in a salutary manner, 
excite the whole vascular system and its connected secreting 
organs, and may thus wash out of the blood various effete or 
noxious matters; and this is a chief good which the "water-cure" 
sometimes effects. The free use of liquids is supposed, by Prout, 
to prevent the formation of lithic acid, or, according to Liebig, it 
facilitates its conversion into urea. On the other hand, a total 
abstinence from liquids for two or three days is an effectual mode 
of stopping fluxes, and of relieving catarrhal inflammations and 
congestions. Either plan exerts an alterative operation on the 
circulation and secretions, which, if more studied, may perhaps 
be turned to good account in the treatment of many diseases. 



SECTION XIII. 

CHANGES IN THE BLOOD BY RESPIRATION. 

232. The process by which venous blood is made arterial, and 
rendered fit for its purpose of maintaining the life and functions 
of the several parts of the body, is liable to variations; and the re- 
sulting differences in the state of the blood form an important 
element of disease. 

The conversion of venous into arterial blood comprises the 
absorption of oxygen, the removal of some carbonic acid, a slight 



ELEMENTARY CHANGES IN THE BLOOD BY RESPIRATION. 123 

increase of fibrin, and possibly other changes. Each of these 
elements of the process is probably concerned in giving to arterial 
blood its fitness for its function; the absorbed oxygen, by its affi- 
nity for the hydrogen and carbon of the blood and textures, aid- 
ing in those processes by which these are renovated in function 
as well as in structure and heat is evolved; the renewal of fibrin 
supplying the expenditure of the plasma, particularly in the mus- 
cles; and the removal of the carbonic acid being the excretion of 
a noxious matter. 

233. It is doubtful whether this change is ever carried on in 
excess; for by an admirable adaptation, the activity of respiration 
is proportioned to the rapidity of the circulation and the corre- 
sponding need of change in the blood. Thus exercise, which 
accelerates the circulation and changes of the blood, also aug- 
ments the breathing movements. In fevers also, the frequency of 
the pulse and of respiration is increased; but the muscular strength 
being much impaired, it is doubtful whether the rapidity of the 
circulation or the real amount of the respiratory changes is gene- 
rally augmented in proportion. It has been said, that in acute 
rheumatism the circulation and respiration are too active for the 
wants of the system, and that the blood reaches the veins without 
having wholly lost its arterial character. If this were true, it 
might in some measure explain the great increase of fibrin in the 
blood in this disease; but the fact is not well established.* 

234. Defect of the change in the blood by respiration is a com- 
mon and important element of disease, and constitutes a chief 
feature of affections of the respiratory apparatus. Being the 
essence of the special disease asphyxia or apncea, its minute con- 
sideration belongs to special pathology, and we shall here only 
describe it in its more general characters. 

The amount of mischief arising from defective respiration varies 
greatly according to the sudden or the gradual supervention of 
the defect. An acute attack of the organs of respiration may 

* It seems to me that Professor Liebighas given too mechanical a view of the 
change of the blood in respiration. He appears to consider the increased arterial- 
ization of blood, during exercise and on exposure to cold, to be a necessary conse- 
quence of the greater amount of air inhaled, in one case by accelerated movements 
of the chest, in the other by the greater density of the cold air. But if the extent 
of the changes wrought by respiration were in exact proportion to the quantity 
of oxygen received into the lungs, how easy would it be to increase them (and 
thereby animal heat also) by voluntarily augmenting the respiratory movements. 
I cannot but think that the proportion of oxygen absorbed, and of carbonic acid 
formed, depends more on the condition of the blood brought to the lungs; and 
that the respiratory movements are regulated by this. Thus the increased oxy- 
genation of the blood is a consequence, not a cause, of greater changes pre- 
viously wrought in tlic> blood itself. 



124 ULTIMATE ELEMENTS OF DISEASE. 

prove distressing, and even fetal, by an impediment to the 
breathing, much smaller than that caused by chronic diseases, the 
gradual infringement of which may be scarcely perceived. Thus, 
too, persons affected with extensive emphysema of the lungs are 
habituated to an imperfect state of respiration, which is shown 
by a constant lividity of the lips and cheeks: such an appearance 
would be a sign of approaching death in other persons. The 
cause of this difference is not merely the general fact that sudden 
changes produce more effect than slow changes, but it lies chiefly 
in the fact that the importance of the respiratory function varies 
under different circumstances. When the several parts of the 
body, especially the muscular, are in a state of full activity, more 
breath is needed to remove from the blood the noxious effete 
matter which always results from functional exercise. Hence in 
such a condition (which is that of health) the respiratory process 
cannot be abridged without serious disorder. This disorder is 
first obvious in the increasing feelings of oppression and suffocation 
which the want of breath causes, and which excite forced exer- 
tions to breathe. If these exertions still fail to duly aerate the 
blood, it is partly arrested in the lungs, right compartments of the 
heart and veins, and part passes in an imperfectly arterial state 
to the left side of the heart and arteries. 

235. The phenomena of asphyxia are thus compounded of — 
1, accumulation of blood in the venous system; 2, diminution of 
blood in the arterial system; and 3, deficiency of oxygen and 
excess of carbonic acid in the blood. These several conditions 
cause injury to the vital functions, both by the want of a due 
supply of blood, and by the bad quality of that blood, which is 
injurious, — negatively for want of oxygen, the proper exciting 
agent, and positively from its excess of carbonic acid and other 
excrementitious matters which arc sedative. The symptoms in- 
duced are also of two classes — 1, those implying failure of func- 
tion, such as muscular debility, feeble action of the heart, coldness 
of the surface and extremities, and abolition of the senses and 
mental faculties; and 2, those arising from congestion and the 
noxious influence of the black blood, such as palpitation, flashes 
in the eyes, noises in the ears, delirium, muscular spasms, &c. 
Each of these sets of symptoms may predominate in different 
cases, and this causes a variety in the phenomena of asphyxia, 
which has not been sufficiently noticed by writers on this subject. 

236. But we have to notice the other mode in which the 
changes by respiration may become defective, that occurring 
gradually, or when the functions are not active. It is well 
known that hybernating animals breathe scarcely at all, and yet 
they live; and this is obviously because their functions are re- 
duced to an extremely torpid state. So, too, animals newly born 



ELEMENTARY CHANGES IN THE BLOOD BY RESPIRATION. 125 

will bear the privation of air for a much longer period than thdse 
which are older; and it has been supposed that in adults failure 
of the heart's action by syncope retards the operation of as- 
phyxiating causes. (Dr. Carpenter, on Asphyxia, Library of 
Med., vol. 3.) 

237. Although man cannot be reduced to the torpidity of hy- 
bernation, yet it is certain that he may be brought to bear a 
defect in the respiratory changes, which would be fatal in a few 
minutes .under common circumstances. This is seen when the 
defect is congenital, as in those affected with malformations of 
the heart causing cyanosis; and it is also seen where the defect 
is very gradually induced, as in the case of emphysema of the 
lungs. 

238. In cases of cyanosis, (the blue disease, in' which, from 
malformation of the heart, some venous blood passes into the 
arteries,) we have the opportunity of observing the more essen- 
tial effects of defective arterialization of the blood. Individuals 
thus affected are in a lower scale of animation. The slower pro- 
cesses of nutrition and secretion seem to go on pretty well, but 
the muscular power is low; slight exertions bring on symp- 
toms of faintness, palpitation, suffocation, or insensibility; the 
animal heat is lower than natural, and there is greater suffering 
from the influence of cold. In short, all the powers of body and 
mind are slender, and are easily disordered by any circumstances 
which tax their activity. In the few that reach mature age, there 
is no sexual passion, which seems to be a happy provision against 
the chance of perpetuating a malformed race — human reptiles. 
The subjects of cyanosis are said to be very liable to haemor- 
rhages, and when these occur spontaneously, or from accidental 
causes, it is very difficult to stop them. This must be ascribed to 
a defect of fibrin which we have already found to occur where 
the changes of the blood by respiration are imperfect, (§ 196.) 
The same defect occurs in the foetus. 

239. In connection with the" scantiness of fibrin in the blood, 
when the respiratory changes are defective, Ave must notice the 
weakness of the muscles generally, which' are probably, nourished 
by the fibrin. This weakness is often observed in the subjects of 
extensive disease of the lungs, especially emphysema. In these 
same subjects-the deposition of fat is, on the other hand, often 
excessive, which agrees very well with Liebig's idea that respi- 
ration directly consumes the oily parts of the blood; the respira- 
tion being defective, the fat accumulates, (§ 224.) 

2-10. Remedial measures.— llcsides the obvious indication of 
endeavouring to restore the respiratory function where it is de- 
fective, the view which we have taken of the mode in which the 
11* 



126 ULTIMATE ELEMENTS OP DISEASE. 

defect is hurtful, suggests means by which its injurious effect 
may be diminished. Thus circumstances which lower the acti- 
vity of the functions often give relief. Of these complete rest of 
body and mind; warmth to the surface and extremities, whilst air 
is supplied cool and fresh to the face and air passages; and vari- 
ous sedatives, which reduce the circulation and other functions to 
a lower standard (or, in the language of Laennec, diminish the 
want of breath,) such as digitalis, conium, hyoscyamus, &c, are 
the chief. Other medicines, such as aether, belladonna, stramo- 
nium, lobelia, &c, which sometimes relieve dyspnoea, probably 
act in another way, by relieving spasm or other impediments to 
the respiration. 

241. In extreme cases, bordering on asphyxia, the enfeebled 
circulation may require stimulants, and the engorgement of the 
venous system may indicate depletion; in different instances each 
of these conditions may most need attention, and sometimes both 
must be treated in the same case. 

242. Experience has not yet furnished us with the means of 
arterializing the blood by any other process but that of respira- 
tion. This process may in some cases be aided artificially, either 
by mechanical means, as inflation of the lungs, electricity applied 
to the muscles of respiration, the diaphragm, and abdominal 
muscles alternately; and by bronchotomy; — or by chemical means, 
the supply of oxygen or nitrous oxide for respiration. Whether 
the internal administration or the injection into the veins of 
saline and other matters containing much oxygen in loose com- 
bination, such as the chlorates, nitrates, and some peroxides, may 
be made in any degree to supply the delect of respiration, is un- 
certain, but it deserves more extensive trials than it has received. 
If these matters could furnish oxygen to the blood, they would 
yet leave undone the other office of respiration, the removal of 
carbonic acid. Might this be accomplished by the administration 
of free alkalies? In some cases of asphyxia by carbonic acid gas, 
I have thought that some benefit in the progress towards reco- 
very was derived from the use of liquor potassae, with chlorate 
of potash. Perhaps warm baths containing these ingredients 
might be of some use. 

243. The congested state of most organs which occurs when 
the respiratory process is imperfect, renders necessary remedies 
suited to remove this state. The lungs, the brain, and the liver, . 
suffer most. The best remedies in these cases are mercurial, 
and other medicines which act freely on the secretions, (§ 173.) 
Probably these remedies act in part by making the liver assist 
the lungs in the office of decarbonizing the blood. The speedy 
relief afforded to dyspnoea by a bilious diarrhoea has several times 
seemed to me to countenance this notion. 



ELEMENTARY CHANGES IN THE BLOOD BY RESPIRATION. 127 

244. When from disease the respiratory changes are reduced it 
becomes an object not to increase the hydrocarbon of the blood by 
the use of food abounding in fat or containing spirit, but to make 
lean meat and other fibrinous articles, with farinacea and fruit 
abounding hi vegetable acids, the chief sustenance. 

245. There is little to be said on the subject of excess of 
changes in the blood by respiration, as it is not certain that such 
a condition ever exists as an element of disease. It has been 
supposed that in most sthenic febrile diseases in which the 
function of respiration is not impaired, this function must be 
more active in proportion to the accelerated circulation. Acute 
rheumatism gives an example of this kind, and Dr. Christison 
states that the blood drawn from a vein is much more florid than 
usual. If this be a correct observation, this hyper-arterialization 
of the blood may perhaps account for the unusual quantity of 
fibrin which it presents in this disease. I must, however, remark 
that I have found the excess of fibrin in cases in which there had 
been no remarkable acceleration of the pulse or respiration. We 
shall see hereafter that the increase of fibrin is connected rather 
with the local inflammation than with the fever. 

• 246. From the experiments of the late Mr. Broughton, it ap- 
pears that when animals are confined in oxygen gas, they in the 
course of a few hours die comatose: the respiration first ceases, 
whilst the heart continues to beat with vigour, and the blood, 
even in the veins, is quite florid: it also presents the arterial cha- 
racter of very speedy coagulation. It appears, then, that excess 
of oxygen injures first the nervous function, (§ 154;) but whether 
it does so by exhausting it by previous excitement, or by the 
coagulability of the blood, or by the excessive production of car- 
bonic acid, is not decided by any known experiment. The last- 
named mode is the most consistent with the related phenomena: 
it can scarcely be doubted that an increase of oxygen in the 
blood must augment the production of carbonic acid; and that 
this latter agent may asphyxiate independently of the exclusion 
of oxygen, appears from the experiment of Rolando: he found 
that the air tube of one lung of the land tortoise may be tied 
without materially injuring the animal, but if one lung were sup- 
plied with carbonic acid gas whilst the other received air, the 
animal died in a few hours. (Carpenter's Human Physiology, 
Am. Ed., p. 396.) 

247. Licbig appears to suppose that the poisonous action of 
hydrocyanic acid and sulphuretted hydrogen is due to their ren- 
dering theiron of the red particles of the U I incapable of 

absorbing oxygen from the air, and becoming thus the medium 
of its transfer to the blood and tissues: but to this hypothesis it 



128 • ULTIMATE ELEMENTS OF DISEASE. 

may be objected that the blood of an animal poisoned with 
hydrocyanic acid exhibits the usual changes on exposure to the 
air. Sulphuretted hydrogen does seem permanently to injure 
the composition of the blood, but not the red particles merely; 
for it renders the blood fluid, as well as of a dirty red colour. 
It does not seem consistent with analogy to exclude the fibrin 
and albumen from a share in the absorption of oxygen, as well 
as in furnishing the material on which that oxygen afterwards 
acts. 



SECTION XIV. 

CHANGES IN THE BLOOD BY SECRETION. 

248. Having already noticed this subject under the head of 
diseased secretion, (§ 158,) it will be unnecessary to dwell long 
on it here. 

The most remarkable instance of change in the blood from 
disordered secretion is exhibited in defective secretion of urine, 
(§ 70, 170.) The extreme effects of this element of disease were 
shown in animals in which the kidneys had been extirpated, in 
the experiments first performed by Prevost and Dumas. On the 
third day after the operation, there came on vomiting, diarrhoea 
of a copious brown liquid; fever, with heat varying sometimes 
as high as 110°, and sometimes as low as 92°; pulse very small 
and frequent; breathing laboured: death ensued from the fifth to 
the ninth day. After death there were found effusion of serum 
in the brain, copious mucous in the bronchi, and bilious fluid and 
faeces in the intestines. The liver appeared inflamed (?) and the 
urinary bladder much contracted. The blood was more watery 
than natural, (§ 222,) and was found to contain urea: five ounces 
of blood of a dog yielded twenty grains of urea; and two ounces 
of cat's blood, ten grains. 

249. The symptoms induced in defective secretion of urine by 
degenerative disease of the kidneys are very similar to those just 
mentioned, but more diversified, from the defect taking place in 
different degrees as to amount and time. Thus in acute cases of 
albuminuria, or acute aggravations of old ones, there may be low 
delirium and other typhoid symptoms passing into coma, (§ 129,) 
suffocative catarrh, obstinate vomiting, diarrhoea, or inflamma- 
tory effusions in the serous cavities, any of which may end in 
death. In slower cases, cachexia and dropsy may ensue, the 
blood and solid structures becoming altered. All these effects 
may be traced to the urea and other excrementitious matters be- 
ing retained in the blood; in their greatest amount acting on the 



CHANGES IN THE BLOOD BY SECRETION. 129 

nervous system as a narcotic poison, (.§ 129;) in smaller, acting 
as an irritant, inducing low inflammations in various membranes 
and viscera; and in still lower degree- causing sundry functional 
disorders, fluxes, and dropsies, impoverishing the blood, and in- 
ducing degeneration of certain textures, (§211.) It has been 
already mentioned that the blood in albuminuria loses its proper 
amount of red particles, (§ 185,) and of albumen, (§ 222;) and 
the diminution of these assists. in accounting for the weakness, 
dropsy, and degenerations -which commonly ensue in protracted 
cases. The several results now enumerated may be differently 
presented in different cases, and the treatment should be guided 
according to them. 

250. The effects on the blood of a defective secretion of bile 
have not been so accurately determined. The presence of the 
bile is often obvious in the yellow colour of the serum and fibrin. 
In several cases of fatal jaundice connected with structural dis- 
ease of the liver, I have observed extensive ecchymoses on the 
legs; and I have already stated, (§ 171,) that in most of the cases 
of purpura which I have seen, there has been imperfect action of 
the liver, and the most effectual treatment was by medicines 
which this circumstance would suggest. The presence of bile 
in the blood, although sometimes causing tingling, pruritus, and 
cutaneous eruptions, does not appear to produce local irritation 
and inflammation, or change of the blood and general dropsy, so 
remarkably as tbat of urea does. Still it appears from very pro- 
longed cases of jaundice, in which the dropsy is not local merely 
(ascites), but general (anasarca and hydrothorax), that the blood 
at last is impoverished, and the whole body becomes cachectic. 
Andral found that in dropsical sheep, with hydatids in the liver, 
the albumen, as well as the red particles of the blood, were di- 
minished. 

251. The perspiratory secretion contains lactic acid and lac- 
tates of soda and ammonia, which probably proceed from the 
transformation or decay of the textures, particularly the muscu- 
l;w. Hence these products abound during great muscular exer- 
tion; and when perspiration is checked by external cold, (§ 77,) 
they may be retained in the blood, causing rheumatism, urinary 
disorders, or various cutaneous diseases. The very serious effects 
Bometimes resulting from sudden cold on the perspiring body may 
be partly owing to the same cause, us well as to the disorder 
produced in the circulation.* Rheumatism is especially liable to 

• Dr. R. Willis has recently suggested that checked perspiration may prove 

hurtful by rendering the skin dry, and therefore unfavourable for vital changes 

ed i" take place in the cutaneous capillaries. But if this were the only 



130 ULTIMATE ELEMENTS OF DISEASE. 

occur as an effect of cold, where the body is fatigued with much 
muscular exertion, (§ 30;) and I have frequently observed that 
the rheumatism chiefly affects the limbs which have been most 
exercised. Where the skin fails to excrete, an increased task is 
thrown on the kidneys, whence may result various diseases of 
these organs; and if these organs fail in the task, the lactic acid 
accumulates in the blood, and, probably acting as a ferment, 
(§ 56,) causes the formation of more, and of the kindred pro- 
ducts, lithic acid and its compounds: these, in inflammatory sub- 
jects, excite rheumatic fever; and in more torpid frames, various 
local rheumatic or gouty affections. All these cases are fre- 
quently remarkable for the acid character of the cutaneous and 
renal excretions.* 

252. The remedies for rheumatism, therefore, should not be 
merely antiphlogistic, but also of a kind calculated to eliminate 
the morbid matter from the blood. In slight cases, sudorifics 
may suffice; but in others, the kidneys and Liver should also be 
excited to assist in the process of elimination, and various com- 
binations of colchicum and alkalies with mercury, opium, and 
iodide of potassium, will generally effect this purpose very satis- 
factorily.! 



SECTION XV. 

CHANGES OF THE BLOOD FROM THE TRANSFORMATION OF CHYLE 
AND OF THE TEXTURES. 

253. The changes of the blood from the transformation of the 
chyle and of the textures, including the processes of nutrition 
and reparation, have been examined too little to supply to the 
pathologist any distinct data. Prout, Liebig, and other organic 
chemists, have advanced interesting views on these subjects, but 
they are too hypothetical to be generally applicable to medicine. 
It seems quite warrantable, however, to connect with these 
changes two remarkable states of disease, on the pathology of 
which chemistry has thrown much light, gout and other lithic 
acid diseases, (§ 176,) and diabetes. 

or chief cause of mischief, it might be always removed by the warm bath, or 
any other means of moistening the surface; so too pernicious effects should 
always result from a dry state of the skin: neither of these consists with facts. 

* In a patient with acute rheumatism, I have found the perspiration on the 
affected joints more strongly acid than on other parts. 

f The advantages of this due regard to all the elements of disease in the 
treatment of rheumatism may be shown by the fact, that with few exceptions, I 
have found that three or four days suffice to remove the fever and pain in the 
severest forms of acute rheumatism. 



CHANGES IN THE BLOOD BY TRANSFORMATION. 131 

254. Gout, and the commonest kind of urinary gravel, are now 
generally considered to depend on the production in the system 
of an excess of lithic acid. This acid, being a highly azotized 
compound, is abundantly generated in those who take a large pro- 
portion of animal food, and in whom the digestive and assimila- 
tive processes are impaired. Hence it is produced by high living 
and sedentary habits. It is one of the lower forms of animal 
matter into which the higher principles, fibrin, albumen, gelatin, 
&c, tend to pass in their progress towards dissolution. Hence it 
is produced in excess where there is more azotized matter than is 
wanted for the reparation of the textures, or than the vital assi- 
milating powers can appropriate for this purpose. But it probably 
results also from the decay of the textures, especially during febrile 
or inflammatory irritation, during and after which copious deposits 
of the lithates are seen in the urine. 

The morbid effects of an excess of lithic acid will vary con- 
siderably, according to its amount and other circumstances. The 
kidneys are the proper emunctories by which it is eliminated 
from the blood, and these sometimes suffer from the irritation 
which it causes; hence nephralgia and nephritis may occur: or 
the water and alkali secreted with it in the urine may be insuffi- 
cient to hold it in solution, and it may be deposited in the form 
of sand or gravel, or calculus in the kidneys or bladder; and va- 
rious irritations and obstructions in the urinary apparatus may be 
the result. 

But sometimes the kidneys may fail in their power of elimina- 
tion, (§ 170;) the lithic acid and its compounds then accumulate 
in the blood, and may cause various irritations and functional 
derangements, (irregular gout,) imtil at length some circumstance 
fixes the irritation on a limb, and a fit of regular gout is the con- 
sequence. In this fit, if perfect, inflammation is excited, with 
more or less febrile disturbance, which subsides as a copious de- 
posit takes place in the urine, showing the removal of the morbid 
matter, (§ 165.) The more acute and fixed the inflammation, 
and the smarter the fever, the more abundant is the deposit, and 
the more free is the patient from disease afterwards. On the 
other hand, when the inflammation is low, changing its place, and 
with little fever, it generally tarries long, and the system is not 
relieved. It is when gout thus lasts long, or frequently recurs, 
that often its material so accumulates in the joints as to be depo- 
sited in the form of a plastery or calculous matter, consisting of 
lithate of soda, (chalk stones of gout.) This chronic form of 
goul is connected with a more or Less permanent disorder of the 
digestive or assimilative functions, which renders its treatment 
more dimcull or less successful than that of the more acute forms 
of gout In such cases (chronic,) lithic acid seems to be cngen- 



132 ULTIMATE ELEMENTS OF DISEASE. 

dered in great abundance, being often thrown off in large quanti- 
ties in the urine for an indefinite period, yet never leaving the body- 
free. Such cases are commonly either hereditary or those which 
have been rendered inveterate by intemperate habits, or neglect 
of proper treatment. 

255. In saccharine diabetes, the morbid matter is of a nature 
quite contrasted with that of gout and gravel, being sugar, which 
is wholly unazotized; yet it is probably also produced in connec- 
tion with the processes of assimilation and nutrition — the condi- 
tion of the urine being only a consequence of disorder in these 
processes. The analysis of Ambrosiani, Maitland, and others, 
have proved the existence of sugar in the blood of diabetic pa- 
tients; and Macgregor has also established the fact of its unusual 
production during the process of digestion. The appearance of 
sugar in the urine can scarcely be considered otherwise than as a 
result of its presence in the blood.* But whether it is formed 
only from isomeric principles in the food, such as starch and gum, 
or is also derived from a decay of the textures by a modification 
of the process in which urea is naturally evolved, or is elaborated 
out of various principles botli in the food and in the blood, is not 
clearly ascertained. As there is saccharine matter naturally in 
chyle, it might be supposed that there is, in diabetes, an exagge- 
ration of the process by which this is formed; and that the atro- 
phy and cachexia accompanying the disease result from the drain- 
ing away of the nourishment of the body with the excess of sugar, 
rather than the convcrson of all this nourishment into sugar. El 
is now well ascertained that the ordinary animal constituents of 
the urine are not only present, but are even increased considera- 
bly beyond their natural amount. 

256. There is a resemblance in the indications of treatment in 
gout and in diabetes, although in the fulfilment of these indica- 
tions the means to be employed are most opposite. In both cases, 

* [The contradictory results obtained with regard to the presence of sugar in 
the blood of diabetic patients, is due, chiefly, according to M. Bouchardat, to the 
following circumstance. If you examine diabetic urine at different periods of 
the da}-, you will find that an hour or two after meals it is abundantly secreted, 
contains a considerable proportion of sugar, which successively decreases for 
the next twelve or fifteen hours; beyond this term, if the patient has eaten no- 
thing, no trace of sugar will be found in the urine. Patients are ordinarily in 
hospitals bled in the morning, the period the most distant from their meals, and 
the amount of sugar then in the blood is so minute as to escape detection. By 
two comparative analyses, M. Bouchardat sustains his position. In a patient 
bled at nine o'clock in the morning, who had fasted since five o'clock the pre- 
vious evening, no trace of sugar was detected. In another patient bled two 
hours after a light breakfast, there was unequivocal evidence of sugar in the 
blood.— C] 



CHANGES IN THE BLOOD BY TRANSFORMATION. 133 

we must withhold those articles of diet from which the morbific 
matter is most readily generated. Thus abstinence from animal 
food and stimulating condiments and beverages, in the case of 
gout — the exclusive use of these very articles, to the avoidance 
of all saccharine or farinaceous substances in the case of diabetes 
— constitute a successful part of the treatment. In both cases, it 
is indicated to improve those processes of digestion and assimila- 
tion, from a perversion of which the morbid matter is probably 
generated. But, unfortunately, we know too little of these pro 
cesses, and of means which may influence them, to enable us to 
fulfil this indication with effect. A gouty constitution, in the 
absence of the febrile paroxysm, is often much improved by the 
use of bitters and other mild tonics; and in diabetes, an amend- 
ment occasionally takes place during the exhibition of opium and 
some of the stronger astringents and tonics, such as preparations 
of iron, copper, &c. 

In the effect which each exerts on the economy, there is a great 
difference between the morbid matter of gout and that of diabetes. 
The sugar in the latter has no tendency to accumulate in the sys- 
tem, and produce local effects; but, acting as a powerful diuretic, 
it passes rapidly away, carrying with it a great quantity of water 
and of the other constituents of ordinary urine, (§ 165;) and the 
thirst, dry skin, and emaciation of diabetes, seem to be chiefly due 
to this mode of operation. The common complication of diabetes 
with pulmonary consumption shows also, however, that the plas- 
tic process is degraded, (§ 211.) 

The lithic acid of gout and gravel, on the other hand, has a 
tendency to accumulate in the body, and to cause the local and 
general irritations which have been already mentioned, (§ 254.) 
Hence it becomes a chief indication to counteract its irritating 
properties, and to promote its elimination from the system. The 
medicines which are most efficacious in doing this are alkalies, or 
their carbonates, or their vegetable salts, with colchicum, or iodide 
of potassium, saline mineral waters, and alterative aperients. 
These increase the action of the kidneys and intestinal canal, and 
drain off the offending matter from the system. 

257. It is supposed by most chemists, that the urea excreted by 
the kidneys is chiefly derived from the transformation or decay 
of the textures of the body, (§ 254,) most of their carbonaceous 
matter being abstracted by the affinity of the oxygen of the blood, 
and carried off by the lungs in the form of carbonic acid gas, 
(§ 232.) The causes which increase the production of urea are, 
according to Liebig, those which excite the activity of the func- 
tion of respiration, which supplies the consuming oxygen, espe- 
cially active bodily exercise. Under some circumstances, however, 
12 



134 ULTIMATE ELEMENTS OF DISEASE. 

the formation and excretion of urea is much augmented, without 
any obvious excitement of the respiratory function. This is the 
case in the diabetes ureosus described by Dr. Prout, and which 
he considers a forerunner of saccharine diabetes. Such sponta- 
neous production of the matter, which seems to be a kind of debris 
of the body, indicates organic weakness, and has been observed 
to occur in young persons who have grown rapidly, and in those 
weakened by venereal excesses. An excessive excretion of urea 
(or of carbonate of ammonia, which is of kindred composition,) 
sometimes takes place in typhoid fevers, and is attended with 
great loss of flesh and strength. A great and sudden increaseof 
urea in the urine was ascertained to have taken place, in some 
patients, with acute rheumatism, in University College Hospital, 
at the decline of the fever and other symptoms. This perhaps 
ought to be viewed as arising from the removal of that which 
had accumulated rather than from an increased formation of urea; 
and this fact may be connected with that ascertained by Professor 
Chelius and Dr. Lewins, that colchicum causes an augmented 
discbarge of this and other principles of the urine, (§252, 173.) 

In cases of excessive formation of urea, all circumstances which 
depress or exhaust the organic life must be avoided, such as great 
excitement of body or mind; waste must be supplied by a gene- 
rous diet, and the nutritive function sustained by tonics. Opium 
and other narcotics are found to be useful in reducing the urine 
in the diabetes ureosus; and it is not improbable that their opera- 
tion is directly on the vital part of the process of transformation 
of the textures, as much as on the respiration. 



SECTION XVI. 

CHANGED PROPERTIES OF THE BLOOD FROM THE PRESENCE OF 
FOREIGN MATTERS. 

258. The blood is probably the chief seat of the morbid poisons 
which excite various contagious, (§ 93,) epidemic, (§ 88,) and 
endemic diseases, (§ 81.) Probably, too, it is the hot-bed in 
which some of them are propagated, (§ 99,) and it is through 
changes in its composition that many of the destructive effects of 
these poisons are produced, (§186, 196.) We have already no- 
ticed some of these changes under former heads. It will suffice 
in this place to mention a few examples in which morbid poisons 
have been traced to the blood. 

Dr. Francis Home communicated measles from one person to 
another by inoculating with the blood of a patient affected with 
the disease. M. Gendrin describes the following experiment: — 



CHANGES IN THE BLOOD BY FOREIGN MATTERS. 135 

A man who had been skinning a diseased animal was seized 
with a putrid fever, attended with an eruption of sloughing pus- 
tules. Some blood taken from this man was injected into the 
cellular texture of the groin of a cat; the animal was soon 
affected with vomiting of bile, dyspncea, frequent small and irre- 
gular pulse, dry brown tongue, slight convulsions, and died 
seven hours after the injection. The same pathologist, produced 
in annuals various severe symptoms, speedily ending in death, 
by injecting into their veins blood from a person labouring under 
confluent small-pox. MM. Dupuy and Leuret communicated to 
a healthy horse the malignant pustular disease called "charbon," 
by injecting into its veins blood from a diseased animal. [From 
the experiments of M. Renault it would seem certain that the 
blood is essentially diseased in glanders. By injecting the blood 
of a horse labouring under glanders into the veins of a healthy 
horse, he was enabled to communicate the disease. — C] Andral 
quotes from Duhamel an extraordinary case, in which blistering, 
pustules, malignant fever, and death, followed the mere contact 
on the lips of the diseased blood of an animal. Other instances 
are on record of sickness, faintness, and serious illness being 
caused by the odour of blood; and Dr. Copland tells a mar- 
vellous story of three persons being struck dead by the smell of 
the blood in the plague. 

259. There is good reason to suppose that purulent matter, and 
the germs (§ 90) of carcinoma, and other forms of malignant dis- 
ease, are spread through the system through the medium of the 
blood. The tendency to symmetrical arrangement which cuta- 
neous eruptions, nodosities of the joints, paralysis from lead, and 
some other local affections exhibit, has been adduced by Dr. W. 
Budd and others, as an instance of effects produced through the 
medium of the blood — the symmetrical distribution of this fluid 
on the opposite halves of the body leading to like results in cor- 
responding parts. 

260. In the treatment of this element of disease, foreign mor- 
bific matters in the blood, the two indications which present 
themselves are — 1. To counteract the injurious operation of 
these matters; and, 2, To expel them from the system. The 
first of these indications is followed, when we give stimulants to 
overcome the depressing influence of adynamic fevers and other 
sedative poisons; and when opium and other narcotics are ad- 
mit list 'i vi I where irritation prevails. We do not possess chemi- 
cal antidotes which can act ou the foreign matter in the blood 
without injuring the blood itself. The other indication is more 
generally pursued, although little recognized by practitioners, — to 
expi I the offending matter from the Bystem. The excretory 
organs, especially the kidneys and alimentary canal, are the 



136 ULTIMATE ELEMENTS OF DISEASE. 

natural emunctories through which foreign and offending matters 
are expelled from the blood; and hence the utility of alterative 
aperients and diuretics, (§ 173, 174,) in the treatment of fever 
and other diseases connected with poison or injurious matter in 
the blood. Orfila found that the pernicious effects of small re- 
peated doses of arsenic in animals might be averted by giving at 
the same time a diuretic medicine. Let us bear in mind how 
often fevers and other serious ailments seem to be carried off by 
spontaneous diarrhoea, diuresis, or perspiration; and, perhaps, 
sometimes by these discharges artificially excited. Nor should a 
converse fact be overlooked, that persons affected with disease of 
the kidney, (cacoplastic degeneration,) which impairs its excernent 
function, are peculiarly liable to contract infectious diseases, and 
to suffer from their effects, (§ 17, 26, 32.) 



CHAPTER III. 



SECONDARY OR PROXIMATE ELEMENTS OF DISEASE, 
CONSISTING OF TWO OR MORE PRIMARY ELEMENTS, 

(§ 504.) 



SECTION I. 



261. The class of proximate elements which have been most 
generally studied as the subjects of general pathology, are those 
affecting the circulation of the blood. They comprise at least 
three of the primary elements which have been considered — the 
blood and its constituents, and the moving and tonic fibre, 
(§ 110, 120,) concerned in its distribution. A previous acquaint- 
ance with these elements will render very intelligible many of 
the kinds and phenomena of their compounds, but it is necessary 
to keep in view also the physical properties of the vessels and 
their contents; for these properties, when altered, become ele- 
ments of disease. Thus a mechanical obstruction or an enlarge- 
ment of a blood-vessel contributes to the formation of disease as 
much as a change of vital properties. So it is impossible to un- 
derstand the effects of too much or too little blood in the vessels, 
without a due consideration of the mechanical qualities of these 
vessels. 

We shall briefly consider the morbid conditions connected with 
defect, and excess of blond in the vessels, under the divisions of 
general and partial, and as attended with an increase or dimi- 
nution of the irritability and tone of the moving fibre. It is to 
be understood that all the proximate elements of disease now to 
be considered, may occur either as distinct affections or in combi- 
nation with other maladies. 

2(>2. tflnsemia, or as it has been more correctly termed, hyphe- 
mia, or oligsemia, is the name applied to thai condition of the 
system in which the predominant character is a deficiency of 
blood. Ii is often symptomatic of various maladies, particularly 
chronic and cachectic affections; but it sometimes occurs without 
12* 



138 PROXIMATE ELEMENTS OF DISEASE. 

any other known disease, and its symptoms exemplify in a 
striking manner the mode in which the various functions suffer 
for want of a due supply of the vivifying fluid, (§ 183, 185.) 

Thus the general symptoms of anaemia are those of weakness, 
(§ 116;) general muscular weakness, evinced by the faintness, 
breathlessness, and fatigue caused by exercise; weakness of the 
heart, shown by the feeble, loose, or thready pulse, rendered very 
frequent and palpitating by slight exertion, and often irregular 
and failing afterwards; feebleness of the whole circulation, 
(§ 123,) manifest in the coldness of the extremities; organic weak- 
ness, shown by the loss of appetite, indigestion, torpor of the 
bowels, scanty N and disordered secretions, (§ 172;) defective nu- 
trition, (§ 211,) especially of the muscular parts; and imperfect 
sanguification, for the remaining blood becomes diseased, being 
poor and watery, as well as scanty, (§ 185, 222.) 

263. There are also distinctive physical signs of the scantiness 
of blood in the body: the surface is remarkably pallid, and even 
the lips, gums, and tongue, show none of their healthy ruddiness. 
The complexion may vary the amount and kind of the paleness, 
dark persons often appearing very sallow, or even of a yellowish 
or greenish tint, (whence the term chlorosis,) and those of fair 
complexion having a ghostly paleness. If blood-vessels are seen 
at all, it is only the larger superficial veins, which are pink in- 
stead of blue, from the paucity and transparency of the blood in 
them. In the course of the larger veins, especially the jugulars 
in the neck, the thin blood, running with great rapidity in the 
ill-filled vessels, is often thrown into sonorous vibrations, (venous 
murmurs,) which are sometimes sensible to the finger placed 
lightly on the vein. The same thinness of the blood, together 
with an abruptness in the heart's contractions, (§ 113,) frequently 
causes a murmur with the first sound of the heart, referable to 
the aortic orifice: as, however, this murmur varies much in 
different cases, being scarcely audible in some, whilst it is loud 
and harsh in. others, it is obviously dependent in part on some 
irregularity or narrowing at the mouth of the aorta, too trifling 
to give any obstruction or sound when the blood is abundant and 
of due spissitude, but readily causing vibrations and sonorous 
gushes when the fluid is thin and the relations between the size 
of the heart and arteries somewhat changed. 

264. The blood, when drawn, is very thin and Avatery. It 
readily coagulates, and forms a very small contracted clot, 
(§ 207,) generally covered with a buffy coat. This appearance 
is probably due, as Andral surmises, to a predominance of the 
fibrin over the red particles, for these are diminished much more 
than the fibrin, being in extreme cases nearly reduced to one-fifth 
of their natural proportion, (§ 1S5.) The albumen is also often 



AIOEMIA. 139 

scantier than usual; but from the researches of Andral and Dela- 
fond on sheep, it is probable that it is not so in all cases, but 
chiefly in those attended with dropsy, (§ 222.) 

265. Although the symptoms of anaemia are chiefly those of 
great weakness or depression, (§ 262,) there are often others of 
an opposite character, indicating irritation or exaltation of function. 
Some of these arise indirectly from the weakness, as for example, 
pain, nausea, colic, and diarrhoea, (§ 56, 168, &c.,) which maybe 
traced to the weak digestion leading to the production of sundry 
irritating matters from that which has been used for nourishment. 
But other more direct signs of excitement sometimes occur. Thus 
various properties of the nervous system are sometimes exalted; 
sensibility is acute, (§ 126;) there is intolerance of light and 
sound, with flashes in the eyes, noise in the ears, a sense of rush- 
ing in the head, and various neuralgic pains. The excitomotory 
nerves are sometimes excited, (§ 140, 150,) and spasms or con- 
vulsive affections of different kinds may be present, or the organic 
functions may be affected, and palpitation, spasmodic asthma, 
vomiting, and such sympathetic irritations, may occur. In a few 
instances, anaemia has been attended with delirium, or mental 
excitement bordering on it. 

266. It thus appears that the functions which sometimes are 
excited in the midst of general depression and weakness, are 
those of the nervous centres; and the generally nervous character 
of persons in a state of great weakness (§ 113) is connected with 
the same fact. No explanation of this apparent anomaly has 
been to my knowledge proposed; but one seems to suggest itself 
in I he peculiar distribution of the circulation through the nervous 
centres. When the mass of the blood is reduced in quantity, 
the blood-vessels generally contract in proportion, their tonicity 
adapting them to the amount of their contents, (§ 120.) But the 
vessels within the skull and spinal canal cannot contract with the 
same facility, for not being exposed to atmospheric pressure, and 
some of them being fixed in bony canals, they do not shrink as 
the blood becomes reduced, and therefore they retain more than 
their proper share of the circulating fluid.* This disproportion- 
ate amount of Mood in the nervous centres produces different 
effects, according to the degree in which the heart's propulsive 
power (§ 111) reaches it. Under the influence of palpitation, 
(§ 112,) fever, or other kind of excitement, the brain and spinal 

* This statement is ool invalidated by the recent experiments of Dr. G. 13nr- 
(Med. Gaz., April, 1843.) Jtis experiments and expositions very satis- 
factorily demonstrate the absurdity of the notions, founded on l>r. Kellie's pane*, 
that the quantity of blood in the head is always the same; but it remains clear 
that the circulation within the head and spinal canal, especially in man, is af- 
fected by lusses of blood, differently from the circulation in other parts. 



140 PROXIMATE ELEMENTS OF DISEASE. 

cord receive through their imcontracted vessels an unusual share 
of the force from the heart; an erethism of some one or other of 
the functions of these nervous centres (§ 127, 153, 133,) is the 
consequence; and pain, spasm, sensorial disturbance, or sympa- 
thetic irritations of some kind or another, occur.* 

267. On the other hand, if the heart's action is feeble, (§ 116,) 
it may be inadequate to propel the blood accumulated in the ves- 
sels of the brain; it therefore stagnates, and may cause some of 
the symptoms of congestion in that organ. Hence headache and 
giddiness, relieved by the recumbent posture, drowsiness, im- 
paired mental faculties, partial paralysis, and, in extreme cases, 
coma or catalepsy, (§ 129, 133, 141.) In such cases the blood 
is accumulated more in the veins and sinuses of the brain than 
in its arteries, and is not moved in proportion to its quantity. 
This congestion may be only temporary, and lead to no serious 
results; but in some cases I believe there occurs an event that 
has not been noticed by pathologists — namely, a coagulation of 
the blood in the sinuses, and a consequent permanent obstruction 
to the passage of the blood through the brain. I have met with 
at least three cases of the following description. 

A young female becomes anaemic, and after exhibiting various 
symptoms of feeble general circulation, with headache, drowsi- 
ness, and impaired sensorial functions, suddenly becomes worse; 
passes into a state of stupor with dilated pupils, sometimes varied 
by slight manifestations of delirium, throbbing of the carotids, 
and partial heat of the head, and dies comatose. On opening 
the head, a small quantity of serum is found under the arachnoid 
and in the ventricles, sometimes with a little lymph, (in one case 
there was none.) The vascularity of the membranes is remark- 
able, but the vessels most distended are the veins, and in the 
larger of these and in the longitudinal sinus, there is a firm coa- 
gulum. In parts, especially at the torcular Herophili, this coagu- 
lum blocks the whole sinus, and exhibits a separation of fibrin, 
portions of which are softened down into that purilaginous matter 
which was long mistaken for pus, but which Mr. Gulliver has 
shown to be a physical change of the fibrin which mere stagna- 

* Although the chief effect of excitement of the circulation in anaemia is thus 
directed to the nervous centres, it is by no means confined to them. Other parts 
in the immediate vicinity of the heart become the seat of increased arterial pul- 
sation and disturbance. Thus a painful throbbing is often complained of in the 
throat, chest, and epigastrium, even when there is little pulse in distant arteries, 
and the extremities are cold. To understand these facts, we must bear in mind 
that when the arteries are full and tense, they oppose their fulness and tension to 
each contraction of the heart, which resistance reduces the strength of each 
pulse in the vicinity of the heart, although it contributes to propagate it to a dis- 
tance; but when the arteries are empty and loose, the heart squirts into them the 
blood in an unresisted jet, the force of which is strong near the heart, but ex- 
tends not to distant arteries. 



ANEMIA. 141 

tion may effect. These have been taken for cases of meningitis. 
No doubt inflammation does supervene in them occasionally, but 
in two cases that have fallen under my notice, there was no ad- 
hesion of the arachnoid nor deposit upon it, nor any other un- 
equivocal mark of inflammatory action; yet the fibrinous and 
bloody concretions in the veins and sinuses were most remark- 
able for their size and firmness,* (§213.) 

It appears to me most probable that these affections originate 
in the encephalic congestion connected with anaemia. Fibrinous 
concretions form on the transverse bands of the sinuses, and in- 
crease until they considerably obstruct the passage of the blood: 
hence the impaired state of the cerebral functions, amounting at 
last to coma. Reaction (§16) may take place, with determina- 
tion of blood, and even inflammation, and these cause those 
symptoms of partial excitement that sometimes exhibit them- 
selves; but neither during life, nor on examination after death, 
are the proofs of excitement so prominent as those of obstruction 
and interruption to the cerebral functions. It must be remem- 
bered that in anasmia the fibrin of the blood is not diminished in 
the proportion of the other animal contents, and it has a greater 
tendency to coagulate than in healthy blood, (§ 207.) 

26S. In anasmia of long duration the process of nutrition often 
suffers, (§ 211,) but by no means uniformly. The cornea some- 
times becomes ulcerated; probably because, being a non-vascular 
texture, it the more needs a nourishing quality of the plasma. 
The muscles become flabby and attenuated; wounds and frac- 
tures sometimes do not readily unite; and in some instances 
spreading, ulcers and sloughy sores form spontaneously on the 
surface. Emaciation is by no means a constant result of anasmia; 
and it is not uncommon to see the most pallid subjects, especially 
females, retain a considerable amount of fat. Dropsical effusion 
into the cellular texture is a common result of anosmia when 
either long continued, or aggravated by additional causes which 
disturb the circulation, (§ 222.) 

269. The exciting causes of anasmia are, various circumstances 
which withdraw blood, (§ 71,) or interfere with its formation, 
(§ 66;) excessive bleedings, or hasmorrhages; profuse evacua- 
tions of other fluids which contain much of the animal parts of 
the blood; scanty or poor food, especially that which contains 
little animal matter or gluten; confinement in impure air, dark 
places, or malarious districts; certain chronic maladies which 

* A wax model of the sinuses and membranes in one of these cases is in the 

una at the University College. Cruveilhier gives a representation of a 

similar case, which, without sufficient reason, he considers as one of cerebral 

phlebitis. Andral mentions a case of cerebral hemorrhage in connection with 

an eemia, which was probably of the same kind. 



142 PROXIMATE ELEMENTS OF DISEASE. 

deeply affect the constitution, such as tuberculous and cancerous 
diseases, and granular degeneration of the kidneys, (§ 185, 222, 
249;) but the commonest cause of all is irregularity of the ute- 
rine function. It is difficult to understand how the last operates; 
but that in many cases it is a cause and not an effect of anaemia, 
is plain from the well known fact that no signs of anaemia have 
occurred until cold, over-exertion, or excitement, or some circum- 
stance, has suddenly checked the flow of the catamenia; it has 
not returned, and then the patient begins to lose colour, and gra- 
dually to exhibit the anaemic state. In many cases I have known 
this occur in young females who have previously suffered from 
acute rheumatism, implicating the heart. It would seem that in 
these cases some injury is done to the bloodmaking process; but 
what, or where, must remain obscure until we know something 
more about the seat and nature of that process. In some of these 
cases of chlorosis, the appetite is depraved, (§ 131;) there is such 
a complete disrelish for animal food and other nourishing articles, 
and such a craving for sour things, and even for matters destitute 
of nourishment, as chalk, cinders, &c, that it .might be supposed 
that this perverted appetite is the cause of the anaemia by deter- 
ring the patient from taking that food which is capable of making 
red blood; and undoubtedly such an appetite, when indulged, 
must contribute to this result; but it is not so constantly present 
as to be considered the only cause of the anaemia in the ex- 
amples under consideration. 

270. Anaemia, in its extreme degrees, may prove fatal suddenly 
by syncope, (§ 71,) brought on by exertion or any additional 
cause of exhaustion; or more gradually, by asthenia, or general 
failure of the vital powers, often attended with anasarca; or by 
developing tuberculous (§211) or other cachectic diseases to 
which the individual may be predisposed; or by the singular 
affection of the head before noticed, (§ 267.) 

[The fundamental and constant character of anaemia is the 
diminution in the red-corpuscles of the blood. Women are 
more subject to it than men, although these may be attacked 
with spontaneous anaemia at all ages. The clot is small, but firm 
and dense, swims in a large quantity of colourless serum, and 
presents on its surface a well-marked buffy coat, which however 
differs from the buff of inflammatory blood by a gradual termi- 
nation in the red-mass, and not by an abrupt, well-defined line. 
(This is due to the excess of fibrin relatively to the globules.) 
When the red-corpuscles are below 80, according to Andral, 
the bruit de soufflet in the arteries is a constant phenomenon. It 
is often heard when their cypher oscillates between 80 and 100, 
and becomes more rare as the physiological mean is approached, 
and when it is reached, ceases altogether. Whatever other dis- 



ANiEMIA — TREATMENT. 143 

ease, besides ansemia, in which this diminution of the red-cor- 
puscles exists, we have this phenomenon; in putrid and eruptive 
fevers, pneumonias, acute articular rheumatism, and in a great 
variety of chronic diseases. The bruit de soufflet is often pre- 
sent in pregnant women, and corresponds with the frequent 
diminution of the red globules in them. 

In spontaneous ansemia the red-corpuscles, alone are affected, 
the other sanguine elements remaining intact; subsequently, how- 
ever, they may become likewise compromised. — C] 

271. Remedial measures. — Most of the measures useful for 
the treatment of anaemia have been already described as those 
suitable to restore a deficiency of red particles and fibro-albumen, 
(§ 193,216.) A nourishing diet, with as much animal food as 
the digestive powers of the patient can master — tonics that best 
restore the appetite, the powers of digestion, and sanguification — 
the use of means, if necessary, to promote the natural excretions, 
(§ 172 et seq.,) and an exposure of the patient to the pure air 
and light of heaven, as free as the strength and sensibility will 
bear — form the chief items of the treatment. 

The adaptation of this treatment to particular cases will require 
much discretion, especially in proportioning the food to the faculty 
of digestion, and in selecting a tonic that shall not irritate. Where 
it does not disagree, iron, in some of its forms, is unquestionably 
the best tonic; and in many comparative trials, I have found the 
iodide of iron (in solution with syrup) the most speedily effica- 
cious. Besides its tonic action, it promotes the secretions more 
than other preparations of iron; and by its use I have seen 
females restored from extreme pallidity to a rosy hue of health, 
in less than three weeks. The sesquioxyde, citrate, tartrate, lac- 
tate, and ammonio-chloride, are more tardy in their operation; 
and the sulphate and sesquichloride are apt to nauseate, or other- 
wise disagree; but each is found occasionally useful, and so are 
chalybeate mineral waters. In some cases any preparation of 
iron causes headache, fever, sickness, or some other symptoms of 
disorder; and then milder tonics, as calumbo or other bitters, with 
mineral acids, or with iodide of potassium, are more suitable at 
first; and the stronger tonics, with iron, may be given afterwards. 
In extreme cases, as those after excessive losses of blood, I have 
found it very useful to give sulphate of quinine at the same time 
as the iodide, or some preparation of iron. 

The success of the treatment becomes manifest, not only in the 
return of a healthy colour to the lips and skin, size to the super- 
ficial vressels, and strength to I he pulse, but also by an improve- 
ment in nil the functions, breath, strength, digestion, &c. It is a 
curious lint thai the venous murmurs, (§ 263,) although dimi- 
nished, are not so in proportion to the apparent return to health. 



144 PROXIMATE ELEMENTS OF DISEASE. 

272. Besides these general measures, indicated for all varieties 
of anaemia, particular cases require temporary measures, on the 
one hand, to prevent faintness or excess of weakness, (§ 262;) 
on the other, to subdue nervous excitement, (§ 265,) and coun- 
teract the congestion in the head, which we have found to occur, 
(§ 267.) Diffusible stimulants, such as carbonate of ammonia, 
valerian, aether, wine, and spirits, are often useful as temporary- 
means of obviating the extreme weakness. Nervous symptoms 
may be treated by various narcotics, such as hyoscyamus, conium, 
opium, &c. But, inasmuch as these very symptoms seem to 
depend on the irregular distribution of the little blood left in the 
body, they will be the most effectually relieved by reducing this 
irregularity, by warmth and friction to the surface and extremi- 
ties, rest in the horizontal posture, varied with such gentle exer- 
cise as the patient can bear, with pure air, and the judicious use 
of tepid or cold sponging, or shower-bath, (§ 124.) The symp- 
toms of decided cerebral congestion and obstruction have gene- 
rally been treated by antiphlogistic remedies, but with question- 
able advantage. I should expect more benefit from a mild 
stimulant plan, together with derivants, purgatives and diuretics. 
Such a plan commonly answers best in the congestive headache, 
which often troubles anaemic subjects. 

PARTIAL ANJEMIA. 

273. We have the means of studying defect of blood in a part 
of the body in more diversified degrees than defect in the whole; 
and the result we find to be an impaired state of the functions in 
every degree, from that of mere weakness to that of total sus- 
pension and death. Thus temporary pressure on the chief artery 
of a limb soon causes numbness, weakness, and reduction of 
temperature. The same effects result in a more marked degree 
from the ligature of an artery in cases of aneurism, and are gra- 
dually removed as the supply of blood is restored through col- 
lateral arteries. In some such cases, the supply of blood is 
insufficient to maintain the vital properties of the part; then che- 
mical affinities prevail, (§ 50,) decomposition ensues, and the 
part becomes gangrenous and dies. A similar result ensues 
when the arteries of a limb become obstructed by ossification 
and coagulation, as in senile gangrene. This event may be pro- 
duced artificially in animals in forty-eight hours, by injecting 
charcoal powder into the artery of a limb, which totally obstructs 
its capillaries. (Majendie.) It is, most probably, by obstructing 
the circulation, and thus depriving the parts of an element indis- 
pensable for the maintenance of their life, that inflammation and 
other lesions sometimes terminate in gangrene. 



HYPEREMIA, OR POLY.EMIA. 145 

Softening and wasting of textures are also effects attributable 
to continued defective supply of blood. The former is exem- 
plified in softening of the brain and of the heart in connection 
with ossified arteries: the latter in the wasting of parts sub- 
jected to continued pressure. Hence partial anaemia is con- 
cerned in producing many changes of structure arising under 
various circumstances. Deficient supply to secreting organs 
necessarily impairs the amount and quality of their secretions, 
(§ 159.) 



SECTION II. 

HYPEREMIA OR POLY^MIA, EXCESS OP BLOOD. 

274. Too much blood in the system, or in a part, is a most 
frequent element of disease. It implies an undue distension of 
the vessels which contain it; and a modification of the properties 
of these, and of the heart which propels it, is almost constantly a 
concomitant of this morbid condition. The chief vital properties 
of the heart and vessels are irritability and tonicity; excess 
(§ 114, 121) and defect (§ 116, 123) of these form most important 
elements, which modify the effects of excess of blood; and thus 
is suggested synthetically a division (long recognized as most im- 
portant in practice) into active or sthenic, and passive or asthenic 
hyperemia; which distinction is applicable to both the general 
and the partial excess of blood. Another variety of hyperemia 
may be distinguished by an altered or perverted action of the 
vessels, which is chiefly applicable to the affection in a part, and 
includes that singular and complex condition — inflammation. 
A view of these important proximate elements of disease (§ 107) 
is given in the following table: — It is not meant that the dis- 
eased conditions here specified are always separate, or that they 
consist merely of the elements here stated; but these are their 
most distinguishing parts, and most important in regard to treat- 
ment. 



Hypeti- 



blood 



["with motion increased= Sthenic 



General= Plethora-^ 

— diminished=Asthenic 



f with motion diminished=Congestion 

— — increased= Determination of blood 

— — partly increased, 

— — partly diminished=Inflammation. 



Local 



Hemorrhage. 
Flux. 
Dropsy, &c. 



13 



146 PROXIMATE ELEMENTS OF DISEASE. 

SECTION III. 

PLETHORA GENERAL EXCESS OF BLOOD. 

275. As general anaemia may arise from defective formation 
or excessive expenditure of blood, so general plethora may pro- 
ceed either from too much blood being made, or from too little 
being expended. In either case, the blood accumulates and fills 
the heart and blood-vessels beyond the usual degree. But this 
implies a certain activity and health in the processes of digestion 
and assimilation, and also a freedom from any considerable local 
disorder. A person with weak digestion rarely becomes ple- 
thoric; and one who suffers from a local ailment is commonly 
warned by an aggravation of this, before the fulness can become 
general. 

276, The persons who become plethoric arc rather those over- 
flowing with health, who have a good appetite, and indulge it, 
without sufficient regard to exercise and to the excernent func- 
tions. The blood-vessels becoming more and more filled, the 
signs of plethora appear in the red face, distended veins, and full 
pulse; the heart labours with its load, especially on exertion; pal- 
pitation and short breath may ensue, with somnolency and indis- 
position to exertion: but these may attract no further notice than 
to induce the abandonment of exercise. The state of plethora, 
thus gradually induced, may be extreme, without any functions 
materially failing, and yet the subject is on the brink of various 
maladies. It is well it' a great secreting organ is first excited 
under the high pressure, and relieves the system through a free 
discharge, as by mucous or bilious diarrhoea; by bleeding piles, 
&c; or one of these secreting organs may fail in its proper func- 
tion, (§ 170,254,) as the liver or the kidneys; and a bilious attack, 
jaundice, or a fit of gout or gravel, is the consequence. Any of 
these, by establishing a perceptible ailment, disturbs the danger- 
ous ease of the plethoric; and by rendering necessary a temporary 
discipline, saves him from the worse results of plethora — apo- 
plexy, structural disease of the heart, great vessels, kidneys, or 
liver. 

278. Besides the causes already noticed, other circumstances 
may induce plethora. The diminution of an habitual excretion 
or loss of blood, the drying up of a long established sore or issue, 
(§ 270,) or the removal of a limb; all of which diminish the ex- 
penditure from the system, without impairing the blood-making 
process, often become causes of plethora, if no local disorder be 
excited before the vessels in general reach a plethoric tension. 



GENERAL PLETHORA. 147 

279. The division of plethora into sthenic and asthenic arises 
from different proportions of the strength and irritability of the 
moving fibre, which we have noticed as ultimate elements of dis- 
ease, (§ 110 and 120, et. seq.) Where the irritability and tone of 
the heart and arteries are in full amount, the increased quantity 
of blood excites these properties to full operation. Short of dis- 
ease, the functions are active and energetic in proportion to the 
quantity of blood which their organs receive; the heart's action 
and the arterial pulse are strong and regular; secretions are abun- 
dant, sensibility is keen, contractility powerful and in good tone, 
animal heat is sustained, and the mental and bodily powers gene- 
rally are great and active. But beyond this, plethora tends to 
disease: the heart's action is over-excited; the pulse is frequent, 
as well as strong and hard; the face is florid and flushed, and the 
heat is almost feverish; the capillaries of secreting organs and 
surfaces are variously disordered; sometimes excited to excessive 
secretion, sometimes beyond it, to a state of fulness bordering on 
haemorrhage or inflammation; sensibility and sensorial powers 
may be over-excited by the rapid flow, or oppressed by the pres- 
sure of the blood on the nervous centres. If the plethoric state is 
moderate enough to last for some time without immediate disaster, 
the nutritive function will eventually be affected — the heart and 
vessels, and more vascular textures, being the earliest to exhibit 
an increased growth, often with some change of properties. Thus 
may originate structural disease, from the continued excitement 
of sthenic plethora. 

280. Sthenic plethora is that which commonly affects the 
young, the active, and those of sanguine temperament, (§ 41.) 
It comprehends a rich state of the blood, (§ 184,) and an active 
condition of the nutrient function, (§ 195.) Its tendency is to 
cause general febrile excitement, active haemorrhages, fluxes, and 
inflammations. 

281. In asthenic plethora, there is a want of contractility 
(§ 116) and tone (§ 123) in the moving fibre. The heart and 
other organs, instead of being excited by the augmented quantity 
of blood, are oppressed by its load. The pulse may be full, but 
it is slow; sometimes irregular or unequal. There is sometimes 
a tendency to faintness alternating with palpitation; physical 
examination shows the heart to be enlarged by the accumulation 
of its contents, which it cannot expel. The face is purple rather 
than ivd; the veins arc, generally distended; sometimes the ex- 
tremities arc apt to become cold. Other functions are sluggish, 
and imperfectly or irregularly carried on. The bowels are 
torpid, the urine high coloured or turbid, sensibility is blunted, 
and the mental facilities dull, with lethargy or somnolency. 

Asthenic plethora affects especially those weakened by age> 



148 PROXIMATE ELEMENTS OF DISEASE. 

excesses, or previous disease, and those in whom the excreting 
organs act imperfectly; which imperfect action is a cause, as well 
as a consequence of plethora. Asthenic plethora tends to pro- 
duce congestions and passive haemorrhages, and fluxes or drop- 
sies; and if continued, structural changes in some organs, as 
dilatation of the heart, enlarged liver, varicose veins, &c. Con- 
gestion of the brain, with apoplexy or palsy, headache, or other 
symptoms of disturbed, function, sometimes is produced; or if 
there be any organ, the vessels of which, from past or present 
causes, (§31, 32,) are weak, this organ maybe the first to suffer. 

282. The symptoms of asthenic plethora hitherto described are 
chiefly those of a depressed or oppressed state of the functions. 
Sometimes, however, there arise others betokening excitement or 
reaction of an irregular kind. The pulse becomes quickened, 
and often irregular; the skin becomes hot, or partially perspiring; 
sickness and vomiting may occur; the tongue becomes much 
farced, and sometimes brown and dry; the excretions are un- 
usually offensive, and often changed in appearance; the com- 
plexion becomes dusky, the eyes suffused, the mental faculties 
disturbed or impeded in delirium or sopor. This is a kind of 
congestive fever, described by Dr. Barlow as a result of reaction 
from asthenic plethora. It is probable that this description has 
been partly drawn from cases in which, besides asthenic plethora, 
some morbid poison (§ 258) has been in operation; but many of 
the symptoms here named may be fairly traced to a congestive 
f ulness of the blood-vessels, with an impaired action of the excret- 
ing organs, (§ 70, 171, &c.;) and consequently, the diseased con- 
dition of the blood, which we have described to arise from 
imperfect excretion, (§ 248, et seq.) The process of reaction or 
febrile excitement, which occurs hi cases of asthenic plethora, is 
sometimes more distinctly connected with the condition of the 
blood, as in the case of gout, (§ 254,) rheumatism, (§ 251,) and 
various cutaneous diseases, which become developed generally 
in the less inflammatory forms. 

[In thirty-one individuals suffering from well marked ple- 
thora, the mean of the fibrin was 2-7, which is rather below the 
healthy standard. Plethoric persons are consequently not more 
liable to inflammatory diseases than others, and an appeal to 
clinical experience will sustain this assertion. The organic ma- 
terials of the serum do not offer any remarkable alteration in 
proportion or composition in plethora. The blood of plethoric 
persons is very highly coloured. On coagulation the serum will 
be found more or less deeply tinged; the clot is larger, of mode- 
rate consistence, and contains a good deal of serum, and is never 
buffed. If the blood has flowed very rapidly from the vein, there 
is sometimes a thin, transparent pellicle on the surface. 



GENERAL PLETHORA. 149 

111 plethora all the organic functions are more actively per- 
formed. There is a remarkable disposition to exaltation in the 
cerebral functions; the emotions are frequent and very mobile, 
without however, those exaggerations and aberrations of sensi- 
bility, those nervous predominances, which almost constantly 
occur in anaemia. Plethoric persons are liable to certain acci- 
dents, as vertigo, dimness of vision, ringing in the ears, and heats 
in the head. These symptoms have been usually attributed to 
cerebral congestion, a condition which has, however, never been 
ascertained. Andral thinks these phenomena sufficiently ac- 
counted for by the passage of an increased quantity of red cor- . 
puscles through the vessels of the brain. It is strange that, as 
we have seen, (§ 264,) opposite conditions of the red corpuscles as 
regards quantity, produce analogous phenomena. Plethora pre- 
disposes to haemorrhages. The bruit de soufflet never occurs in 
plethora, as has been erroneously stated. — C] 

283. Remedial measures. — The means already described as 
useful in reducing an excess of red particles (§ 192) and fibrin 
(§ 214,) are also applicable to the earlier and simpler states of 
plethora. In fact, in these states, the blood usually does exhibit 
this excess, for which blood-letting and other evacuants, and ab- 
stinence, are the chief remedies. The propriety of blood-letting 
in extreme degrees of plethora is evinced by the extent to which 
it may be carried without causing faintness. Thus Dr. M. Hall 
found, that from patients with congestive apoplexy, from forty to 
fifty ounces might be drawn without producing syncope; whilst 
in acute inflammation, the tolerance is usually less by about ten 
ounces. The beneficial effects of blood-letting are sometimes 
immediately manifest, although they are somewhat contrasted in 
the two varieties of the disease. In the sthenic kind, the pulse 
becomes softer, weaker, and less frequent; in the asthenic, it 
often improves in strength and regularity, and sometimes rises to 
a natural frequency. In simple and recent cases of both kinds,- 
a sufficient blood-letting, with due avoidance of the causes of the 
plethora, (so far as that can be accomplished,) and the use of a 
little aperient medicine, may complete the cure. 

284. But if the plethora have lasted long enough to produce 
some of its ulterior effects, (§ 282,) blood-letting may be an in- 
sufficient, nay, in some instances, it may be an unfit remedy. In 
both kinds of plethora, medicines which increase the secretions 
are generally indicated, and tin; diet must be much restricted; 
but the particular mode in which these ends are to be accom- 
plished, varies greatly in tin; two forms which I have been care- 
ful id distinguish. 

285. In sthenic plethora, not only the blood is in excess, but 

13* 



150 PROXIMATE ELEMENTS OF DISEASE. 

also the irritability and tone of the moving fibre. Here, then, be- 
sides removing the excess of blood, sedative and relaxing reme- 
dies (§ 115, 122) are indicated. Antimonials, salines, digitalis, 
and hydrocyanic acid, and a cool regimen, we have found to an- 
swer this purpose; and these are often most useful in the treat- 
ment of sthenic plethora. The same remedies, with mercury, 
colchicum, and some others, fulfil also another indication, which 
may be presented, to augment excretions defective from an over- 
excited state of the capillary circulation, which borders on haemor- 
rhage or inflammation. If any part should especially suffer, local 
blood-letting may be requisite to prevent such a result. 

286. In asthenic plethora of some duration, on the other hand, 
although blood-letting relieves them, it does not restore lost tone 
to the over-distended vessels. Tonics, (§ 124,) and even stimu- 
lants, (§ 119,) may be necessary at the very time that blood is 
drawn; and there may long be required such treatment as is cal- 
culated to restore the impaired functions of digestion and secretion, 
and to improve the depraved condition of the blood, (§ 174.) In 
such cases, the continued use of alterative aperients and diuretics, 
such as mild mercurials, with rhubarb, aloes, or senna, salines, 
and taraxacum, nitric acid, iodide of potassium, &c, may prepare 
the way for various tonics, such as calumbo, bark, and iron. In 
such cases, mineral waters, like those of Cheltenham, Harrowgate, 
and Llandfidod, are often, of great service; first the saline, which 
are aperient and diuretic, and afterwards the chalybeate, which, 
although tonic, usually contain enough saline matter to keep the 
secretions free. Some of the latter class, as the Bath waters, 
sometimes excite torpid and plethoric habits to a critical reaction, 
by bringing on a regular fit of gout, (§254.) 

The diet, which should be very spare in sthenic plethora, must 
not be too much reduced in that of the asthenic kind. The food 
should be simple, but nourishing, and adapted to the power of 
digestion. Stimulant drinks are not generally necessary; but pre- 
vious habits must be considered, and not suddenly reversed. Regu- 
lar out-door exercise, as much as the strength will bear without 
causing excitement or exhaustion, is a most salutary part of the 
regimen. 



. SECTION IV. 
LOCAL HYPEREMIA. EXCESS OF BLOOD IN A PART. 

I. WITH MOTION DIMINISHED CONGESTION. 

287. The true nature and distinctive characters of congestion 



CONGESTION. 151 

may be conveniently traced through its several causes, all of which 
agree in fulfilling the conditions here given as the definition of 
congestion, excess of blood in the vessels of a part, with dimin- 
ished motion of that blood, (§ 274.) We have already found that 
parts of the vessels, and even the heart itself, become congested 
in asthenic plethora, (§ 2.81;) .but this is as a part'of a more general 
disease. We have now to consider the causes and phenomena of 
congestion of blood in a part, which may occur independently of 
general disease. 

As the great source of the motion of the blood is the heart, 
and the distributors of that motion are' the arteries, we may an- 
ticipate that a chief cause, of diminished motion is a supply from 
the arteries insufficient to propel the blood in the. capillaries and 
veins. . Such an insufficiency occurs when, from whatever cause, 
the capillaries and veins of a part are enlarged, without a corre- 
sponding enlargement of the arteries leading to them. The reason 
of the diminished motion is thus easily found; but we have yet to 
inquire the cause of the other element of congestion, too much 
blood in the part. 

2S8. Blood-vessels become congested, or unduly dilated, when 
their proper elasticity and tone are overcome; and this may 
happen when, an obstruction. in the veins prevents the free escape 
of blood from them, or it may happen from weakness of the 
coats of' the vessels themselves, which yield to : the . pressure of 
the blood transmitted to them. The chief causes of congestion 
may be classed under these two heads: — 1. Those of venous ob- 
struction; and, 2, Those of atony of the vessels, (capillaries 
and veins.) Under these two heads we shall notice various cases 
of congestion, winch will explain and practically illustrate the 
subject. 

289. (1.) Congestion from venous obstruction. — When the 
arm is tied for venesection, the veins are compressed more than 
the arteries. Hence the veins swell, then the fingers become 
red, and after a few minutes purple, and the whole limb is swol- 
len from the congestion of blood in its vessels. In like manner, 
congestions are caused in internal organs by an obstruction of 
the veins leading from them. Thus congestion of the brain may 
be produced by a tight cravat, (§ 51,) or by a tumour pressing 
cm the jugular veins. Straining, (§ 64,) or holding the breath, 
and asthmatic affections, which impede the flow of blood through 
the lungs, cause congestions in various parts. Disease of the 
valves of the heart, which prevents the blood from passing on- 
wards through it, produces fulness of the veins and of the capil- 
laries in both the pulmonic and systemic circulation. Tubercles 
in the lungs cause, congestion of these organs. Obstruction to 



152 PROXIMATE ELEMENTS OF DISEASE. 

the transit of blood through the liver causes congestion in the 
abdomen, haemorrhoids, &c. The characteristic of congestion 
beginning with the veins is, that the veins as well as the capil- 
laries are distended; and this appearance is obvious during life in 
cases of aneurism or other tumour compressing the veins of the 
neck; and alter death in the full arborescent appearance of the 
veins in the congested part. Certain diseases of the organs of 
respiration, especially extensive emphysema of the lungs, in 
which the efforts of expiration predominate over those of in- 
spiration, cause congestions not merely by opposing the return of 
blood through the veins into the chest, but also by removing that 
suction influence which naturally much promotes the flow of 
blood in that direction at each inspiration. It has been pointed 
out by M. Berard, (Arch. Gen. de Med., Jan. 1830,) and by Mr. 
A. Shaw, (Med. Gaz., July, 1842,) that the circulation in the 
liver is, in health, much dependent on this influence; and it may 
be inferred that the diminution of this influence by extensive 
vesicular emphysema will assist in explaining why hepatic con- 
gestion is so commonly combined with this pulmonary lesion. 

290. (2.) Congestion from atony of the vessels. — This com- 
prehends a numerous class of cases. In some the atony of the 
vessels (§ 123) -affects the whole system, as in case of extreme 
debility, adynamic fevers, and the sinking which precedes death. 
The blood thus accumulates in some of the vessels, chiefly those 
that are lowest in the position of the body; which in their weak 
state yield to the accumulating blood. This occurrence of the 
congestion in undermost parts [hypostatic) is the distinctive 
character of that of weakened vessels. Thus the posterior parts 
of the lungs, intestines, and integuments, are found much con- 
gested. 

291. In other cases the weakness is local, without affecting the 
vessels generally, the weakening cause being applied to some 
vessels only. Over-distension is a common cause of congestive 
weakness of vessels. Thus from long continuance in one posi- 
tion, the lower vessels yield to the gravitating force, (§ 51,) of 
the blood, and become congested. This cause makes the feet 
swell after standing or walking long, especially in warm wea- 
ther. A continued stooping posture, or lying with the head low, 
may occasion congestion of the brain, with headache, giddiness, 
confused vision, and may prove an exciting cause of apoplexy. 
Remaining long in a standing or sitting posture, often causes con- 
gestion in the haemorrhoidal veins, liver, uterus, &c. Where the 
circulation is feeble, and the tone of the vessels weak, (§ 123,) 
these causes of congestion operate more readily and more per- 
manently than where the circulation is vigorous; yet these con- 



CONGESTION. 153 

gestive affections, the result of weakness, are often mistaken for 
inflammations. Many of the pains and ailments of delicate 
females are of this nature; and although temporarily relieved by 
depletory measures, are to be permanently counteracted only by 
tonic means, (§ 124,) which promote the vigour and equality of 
the circulation. 

It must be borne in mind that congestion, from mechanical 
causes, when it lasts long, may so weaken the vessels by over- 
distension, as to continue after their original cause has ceased to 
operate. Thus congestion of the brain or lungs induced by a 
paroxysm of dyspnoea, or coughing, or by violent straining, 
(§ 64,) may not subside with the cessation of the effort; giddi- 
ness, headache, pain, dyspnoea, &c, remaining for some time 
after. 

292. In considering the operation of cold as a cause of disease, 
we found that it chiefly operates by constricting the vessels of 
the surface and extremities, and thus throwing the blood in- 
wardly, causing internal congestions by intropulsion, (§ 77.) If 
this exists long, the tone of the internal vessels will be impaired, 
and the congestions will not cease on the restoration of warmth 
to the surface. Thus a permanent congestion in the lungs, liver, 
kidneys, mucous or serous membranes, whichever happens to be 
predisposed, may result; and this congestion may variously dis- 
order the function of the part, or may lay the foundation for in- 
flammation. 

293. Malaria, (§ 82,) and the influences which produce con- 
tinued and exanthematous fevers, (§ 93,) seem to have the same 
effect as external cold, but it is not so easy to explain how they 
operate. The cold stage of these diseases exhibits in a high 
degree the marks of intropulsive congestion; and it is well 
known that in ague the congestive enlargements of the liver and 
spleen are among its most remarkable phenomena. The con- 
gestions remaining during the febrile stages of fevers, seem to be 
the chief cause of their inflammatory complications. 

294. Another cause of congestion is over-excitement of the 
vessels. It is well known that after a part has been inflamed, 
the vessels often remain dilated, but without the signs of inflam- 
mation. This is well seen in the conjunctiva, the throat, the skin, 
and in certain ulcers, and might be exemplified in some internal 
organs. The liver and stomach show many signs of congestion 
after the excitement of stimulant drinks, (§ 50.) But wo may, 
under the microscope, trace the production of congestion apart 
from inflammation. 

When ;i slight irritant, as a weak Infusion of capsicum, is ap- 
plied to the web of a frog, it first causes contraction of the vessels, 



154 PROXIMATE ELEMENTS OF DISEASE. 

especially the arteries, (§ 120,) then quickly follows enlargement 
of the arteries and other vessels with very rapid motion: after a 
While the vessels gradually contract and return to their natural 
s'.ze. But if the stimulant application he repeated several times, 
so as to prolong the determination of blood into the part, the 
vessels do not then uniformly contract. The arteries indeed 
shrink, but the capillaries and veins remain congested, and thus 
present completely the condition given in our definition, excess 
of blood with diminished motion, (§ 287.) This dilated state of 
the capillaries and veins must be chiefly ascribed to their losing 
tone after excitement, (§ 123,) more than the arteries; but the 
process which I have been describing is accompanied by changes 
also within the vessels; numerous lymph globules are formed and 
adhere to the sides of the small vessels, and contribute to impede 
the current and cause congestion by obstruction. Whenever the 
stimulus applied has been strong, this obstruction amounts to 
entire stagnation, and many vessels appear much enlarged, and 
filled with stagnant blood, or rather with an accumulation of red 
particles entangled in the coherent lymph globules. For this 
reason, the vessels in which the blood is stagnant, are of a deeper 
red than others, the red particles being arrested while the liquor 
sanguinis passes on. 

295, All that has been now described belongs to congestion, 
and there can be little doubt that the intense and deep redness 
sometimes seen in congested parts, is partly made up of vessels 
in which the blood is absolutely stagnant. We shall find that a 
similar congestion and stagnation exists also in inflammation, 
and may be the only change left by it to be found after death, 
where the inflammation has not existed long enough to produce 
its more characteristic results. It is for this reason impossible 
to discern by anatomical characters between recent inflammation 
and some forms of congestion. 

2.96. Besides, by its intropulsive mode of causing congestion, 
cold directly produces it by obstructing the capillary and venous 
circulation. This it does partly by its constricting influence, 
(§ 75,) which acts on the veins before it reaches the arteries, but 
from the experiments of Poiseuille it appears that cold physically 
impedes the passage of liquids through tubes, as he supposes by 
increasing their adhesive properties. From a few observations, 
I am disposed to consider that an increased production of lymph 
globules and their adhesion to the vessels operate here also. 

297. Congestion occurs in various organs and surfaces when 
their proper secretions are arrested, or suddenly diminished, 
(§ 167.) It is difficult to determine whether the congestion is 
the effect or the cause of the defective secretion in the first in- 
stance; and very probably the relation is mutual: at least this is 



CONGESTION. 155 

the most convenient view to take of the matter for practical pur- 
poses. Thus means which increase the secretion, (§ 172,) will 
often remove the congestion; and those which relieve the conges- 
tion, generally restore the secretion. 

298. There are some cases of congestion which have not 
hitherto been traced to any of the causes above specified, al- 
though it is not improbable that further investigation may refer 
them to some of these causes. It is well ascertained that when 
the blood does not undergo its proper changes in the lungs, 
(§ 234,) its passage through these organs is partially impeded, 
and it accumulates in the lungs, in the right side of the heart, and 
in the venous system generally. Congestions thus form a promi- 
nent part of the pathology of asphyxia. From the observations 
of Dr. John Reid, it appears that some obstruction also occurs 
to the passage of the blood through the systemic capillaries. 

Again: in Mr. Blake's experiments, various saline solutions in- 
jected into the veins, (salts of soda, silver, &c.,) caused death by 
obstructing the passage of the blood through the lungs, without 
arresting the breath or coagulating the blood. 

It remains for future observers to determine whether these ob- 
structions may be connected with contraction of the vessels, 
(§ 120,) increased spissitude or cohesion of the blood, or other 
simply physical cause; or whether they depend on peculiar (vital) 
attractions and repulsions exerted between the vessel and its 
blood, which properties are supposed by some physiologists to 
constitute an important element in the healthy as well as in the 
morbid phenomena of the capillary circulation.* 

* Whatever influence the vital properties of the blood may be supposed to 
exert in impeding the passage of the blood through the capillaries, I can see no 
reason for admitting that they in any degree contribute to its motion. That the 
power of the heart distributed by the arteries is sufficient to carry on the circu- 
lation, is apparent from several experiments, of which one by my colleague, Dr. 
Sharpey, is the most complete. A syringe, with a hoemadynamometer to show 
the amount of pressure used, was adapted to the aorta of a recently dead ani- 
mal, the vena cava being divided. Warm water was then injected, and with a 
force that raised the mercury in the hcemadynamometer only three inches, the 
water passed through the capillaries and out of the vena cava. When the pres- 
sure was increased, so as to raise the mercury six inches, the flow was very free; 
and on adapting another ha?madynamometer to the vein, the pressure in this was 
found to rise as high as three inches. The pressure thus used in the arteries 
(six inches of mercuiy) was no greater than the natural pressure in the arteries 
of a living animal; and the pressure transmitted to the veins (three inches of 
mercury) was greater than that in the veins of a living animal, thus showing that 
the force of the heart, sustained by arterial tension, is quite adequate to effect 
the circulation without other aid. 

The chief arguments for and against the existence of vital properties of attrac- 
tion and repulsion at sensible distances, have been well stated by Professor Allen 

Tl isoii, in the article, "circulation," in the Cyclopaedia of Anatomy, to which I 

would particularly refer the student. In addition to these, I would slate that in 
many long and careful microscopic examinations of the circulation in the frog's 



156 ULTIMATE ELEMENTS OP DISEASE. 

299. We have considered atony of the small vessels (§ 290) as 
a chief cause of congestion: and it is so, not only by making them 
yield, and become distended by the accumulation of blood, but 
also by rendering them unfit to transmit the force of the current 
in its proper direction. Vessels which have lost their tone, be- 
come inelastic and tortuous, and by the very stagnancy of the 
blood in them, they oppose an increasing obstacle to its passage 
through them. The physical principle to which I now refer is 
not generally understood, and I will illustrate it by some experi- 
ments. 

300. To one of Read's enema syringes, was adapted a tube 
with two arms: to one arm was fitted a brass tube two feet 
long, having several right angles in its course; to the other arm 
was tied a portion of rabbit's intestine, four feet long, and of 
calibre, (when distended with water,) double that of the brass 
tube. The intestine was placed in curves and coils, avoiding 
angles and crossings, which might obliterate the canal. The dis- 
charging end of both tubes was was raised to the same height, 
that of the intestine being kept open by a short tube of metal. 

web, variously modified by different agents. I never witnessed any movement of 
the blood particles, which was not plainly referable to the action of the heart, or 
of vessels. The share which the arteries have in regulating the flow of blood 
through the capillaries and veins, is most evident. When the arteries increase 
in size, the flow becomes very rapid and general; when they diminish the flow 
is tardy, and even ceases in some capillaries; and when the arteries contract, so 
as to permit no blood to pass through them, the blood which still fills the capil- 
laries and veins, becomes quite stagnant, without a sign of spontaneous move- 
ment. When motion begins again, it may always be traced to an artery, which 
first admits a file of single globules, which come few and far between, and in 
pulses; afterwards, as the artery enlarges, many rush in a continuous rapid 
stream, supplying proportionate motion to the vessels beyond. 

Many of the instances of supposed vital motions in the blood, and other organic 
molecules, are referable to mere physical causes. Similar movements may be 
seen, quite as animated in appearance, on mixing under the microscope two 
drops of saline solutions of different strength or nature; any insoluble powder in 
these drops moves, as it were, spontaneously, and the motion continues until 
these drops have entirely pervaded each other. Still more lively motions are 
seen on adding any resinous tincture to water. Similar causes operate on blood 
molecules, giving them motions which appear to be spontaneous. But blood par- 
ticles move also from another cause; they are not only carried by the current, 
but they are often changed in shape by it. Being vesicles, they swell or shrink 
by endosmose and exosmose, on any change in the density of the liquid in which 
they are conveyed; and these changes affect their position and form, their aggre- 
gation and separation, in a manner which might readily give the idea of their 
possessing spontaneous motions. 

Although it seems unwarrantable to admit a self-motory power in the blood 
particles as aiding in the circulation, it is highly probable that changes in them, 
as well as in the vessels which convey them, may impede the circulation. The 
adhesion of the lymph-globules to the sides of the vessels and to each other, 
and, perhaps, the cohesion of the blood-discs, are changes likely to produce this 
effect; but it remains to be proved whether these operate in causing the obstruc- 
tions of asphyxia, &c. 



CONGESTION — CAUSES. 157 

The tubes were then both filled by successive strokes of the pis- 
ton; and when they both began to discharge, the quantity re- 
ceived from each in a given number of strokes, was ascertained. 
Without giving the details, it may be stated that the small metal 
tube. discharged from two to five times the quantity discharged 
by the larger but membranous tube; the difference being greatest 
when the strokes of the piston were most forcible and sudden, 
by which the intestine, although much swelled at its syringe end 
at each stroke, conveyed comparatively little water. The dif- 
ference was ' further increased by raising the discharging ends 
higher; and when both ends were raised to the height of eight 
or ten inches, the gut ceased to discharge, each stroke only mov- 
ing the column of water in it, but this subsiding again without 
rising high enough to overflow. On increasing the force of the 
stroke, the part of the intestine nearest to the syringe, burst. 

The experiment was repeated in various ways, of which I will 
mention one, with a metal tube two feet eight inches long, and 
a bore three-eighths of an inch, and a portion of dog's intestine 
of the same length, but when distended, of double the diameter. 
The metal tube yielded three times more liquid than the intestine. 

301. These experiments show that flaccidity and increased 
length and size of a tube afford impediments to the passage of 
liquid through it; and although the experiments exaggerate the 
difference between healthy and relaxed or congested vessels, yet 
they really prove that the increased tortuosity and number of ves- 
sels in a congested part, the greater mass of their contents, and 
the atonic flaccidity of their coats, do truly form additional ob- 
stacles to the passage of the blood through them, although the 
amount of these obstacles will vary according to the state of the 
connected circulation. 

These experiments illustrate a principle that is too little con- 
sidered in animal and general physics; the loss or neutralization 
of force, by misdirection. The blood-vessels in their healthy con- 
dition are so constituted as to make the most of the heart's 
propulsive power and transfer it throughout their whole length; 
but when dilated, tortuous, flaccid, and otherwise altered, they 
misdirect and exhaust it: (as in the experiment with the intestine,) 
it is partly expended in distending and dilating the nearer por- 
tion, whilst a sufficiency does not remain for the onward propul- 
sion of the blood, which therefore stagnates and accumulates in 
the congested vessels. We shall have many occasions to revert 
to this principle, which explains many anomalies of unequal cir- 
culation. 

302. Without going so far as to say that atony of the capil- 
l.i ries is in this way the chief cause of the obstructed circulation in 

14 



158 PROXIMATE ELEMENTS OF DISEASE. 

asphyxia, (§ 298,) I think that it must be admitted as one cause, 
especially operating when the asphyxiating influence has been 
only a short time in operation. The free supply of air to the 
lungs may soon excite the capillaries to contract, and by restoring 
their natural tone and calibre, remove this cause of obstruction. 
If the congestion remain long, the obstruction is probably in- 
creased, not only by the more permanent loss of tone in the 
vessels, but also by changes in the blood itself, which render the 
removal of the congestion less easy and complete; and it is known 
that when asphyxiating causes have been long in operation, the 
congestions which they have produced are not dispersed by the 
restoration of the respiration. 

THE SYMPTOMS AND EFFECTS OF CONGESTION. 

303. When the arm is tied for venesection, the parts beyond 
the ligature become congested. At first the hand feels rather 
warmer than usual, and somewhat tender, from the distension 
of its vessels with warm blood, but it soon becomes numb, cold, 
and weak, showing that the want of circulation lowers its vital 
properties. 

In like manner, simple congestion generally impairs the vital 
properties of internal organs, although the undue distension of 
their textures, by the increased mass of blood, may cause partial 
excitement. Natural contractility and sensibility are lowered, 
but pain (§ 126,) spasm, (§ 114,) and morbid sympathies, (§ 149,) 
are often excited, although in a manner much less distinct and 
constant than in inflammation or determination of blood. Thus 
congestion of the liver is sometimes accompanied by pain or ten- 
derness; sometimes it is without either. Congestion of the sto- 
mach sometimes causes gastralgia, nausea, and vomiting, and 
altered appetite; but these symptoms are often absent when the 
amount of disease of the liver or heart, and the subsequent oc- 
currence of hsematemesis, leave no doubt that the stomach was 
congested. The same remark is applicable to the kidneys, the 
uterus, the brain, and other organs. We often see the tonsils and 
uvula congested and enlarged, without pain and soreness. Im- 
paired nervous and muscular function is a more constant con- 
comitant than pain, or any symptom of irritation. ' • 

304. The natural secretions of congested parts are sometimes 
at first augmented, as in congestion of the. conjunctiva and 
schneiderian membrane from cold; but more generally they are 
diminished, as in bronchial congestion, (dry catarrh,) and con- 
gestion of the liver, kidneys, &c. But very commonly, conges- 
tion leads to an increased transudation from the whole distended 
capillaries, causing effusions of the watery and saline part of the 



CONGESTION SYMPTOMS AND EFFECTS. 159 

blood, more "or less impregnated with albumen, and sometimes 
even with fibrin, as exemplified in the fluids of fluxes and 
dropsies. 

The process by which this is the effect of congestion or secre- 
tion seems to be chiefly a physical one. The portions of the 
vascular apparatus most concerned in supplying the secreting 
structure, seem to be the middle parts of the capillaries, which 
are often so turned or convoluted, as to receive the most direct 
force of the current from the arteries. But when congested, the 
vessels leading to the middle capillaries become yielding, loose, 
and tortuous, and the force is much expended in dilating these 
before it can reach the secreting extremities:* the secreting por- 
tions are in the condition of the distant end of the intestine in the 
experiment above related, (§ 300,) not duly receiving the force of 
the current. Thus the more essential effect of congestion is. to 
impair the natural secretion. 

305. But the distension of the congested capillaries sometimes 
leads to a general exhalation of their more watery contents, 
which mingling with the natural secretion, render it watery and 
sometimes albuminous. Thus congestion of the bronchi some- 
times ends with bronchorrhoea. Congestion of the intestines 
causes diarrhoea; congestion of the uterus, leucorrhcea; congestion 
of the kidneys, watery and sometimes albuminous urine; conges- 
tion of the lungs and pleura, hydrothorax; of the heart, hydro- 
pericardium; of the abdomen, ascites, &c. 

306. The element of congestion chiefly concerned in the pro- 
duction of these effusions, is distension of the vessels. They are 
less commonly found, therefore, in mere hypostatic or gravitative 
congestions, (§ 291,) in which the distension is inconsiderable, 
but they more result from congestions from venous obstruction, 
(§ 2S9,) especially when these occur suddenly, whilst the vigour 
of the circulation is not impaired. Thus the congestions con- 
nected with diseased heart or liver, produced by acute attacks or 
other additional causes of obstruction, especially in plethoric sub- 
jects, if not soon removed, are pretty sure to end with dropsy, 

* It may seem lhat this is taking too mechanical a view of the process of se- 
cretion: but be it remembered that I do not ascribe secretion wholly to mechani- 
cal agency, but only assert what is known to be a fact, that a due force of the 
capillary circulation is a condition favourable to this process. In lately inspect- 
ing the beautifully injected preparations of Mr. Dalrymple and Mr. Toynbee, I 
was particularly struck with the distribution of the capillaries of secreting sur- 
faces, such as mucous and synovial membranes. These capillaries run pretty 
straight from the minute arteries, and end in loops and lampulla? on the surface, 
the returning vessels passing back as straightly. The physical effect of this pro- 
vision is obviously to direct the chief force on" the terminal loops which supply 
the secreting surface. 



160 PROXIMATE ELEMENTS OF DISEASE. 

flux, haemorrhage, or inflammation. The circumstances that 
determine which of these results shall ensue, will be considered 
when we come to these proximate elements of disease, but it may- 
be mentioned that besides distension of the vessels, the condition 
of the blood considerably influences the result; a watery state 
promoting the transudation, (§ 222,) whilst a highly albuminous 
and fibrinous blood (§ 195) requires more pressure to make its 
watery parts pass through the coats of the congested vessels. 

307. The same circumstances determine the character of the 
effused fluid. Where the blood is poor, the watery parts easily 
pass from congested vessels, even without much distension, and 
contain but little albumen. But if the blood abounds in the pro- 
tein compounds, more pressure is required before much effusion 
takes place; and then, when the pressure is great, the fluid 
effused often contains, not only albumen in large proportion, but 
self-coagulating fibrin also, (§ 211.) Thus I have seen the fluid 
of the pleura and pericardium, in rapidly fatal obstructive mitral 
disease, coagulate spontaneously into a fibrinous crassamentum, 
when removed from the dead body. The gelatinous masses of 
lymph often found in the peritoneal sac of the abdomen and 
pelvis in ascites from contracted liver, I have no hesitation in re- 
ferring to the same origin. 

308. Fluxes arising from congestion of high tension exhibit 
an unusual amount of animal matter of an albuminous or mu- 
cous kind, as instanced in bronchorrhoea, mucous diarrhoea, and 
leucorrhoea. I have been almost induced to suppose that the 
polypous concretions and pseudo-membranous films occasionally 
effused on mucous surfaces may result from long continued con- 
gestion, with a highly fibrinous state of the blood, (§ 195.) I 
have seen these evacuated from the air-tubes, in one case, and, 
in another, from the intestines, from time to time, for months, 
and even years, without symptoms of inflammation, but under 
circumstances rendering it probable that congestion was present. 
Extensive disease of the heart existed in one case, and amenor- 
rhea in the other. 

309. I have for several years referred albuminous urine (§ 249) 
to congestion of the kidney; and this view has been lately con- 
firmed by some experiments by Mr. G. Robinson. The following 
considerations led me to entertain this opinion: — 1. The urine 
often becomes albuminous during great embarrassment of the 
circulation in cases of organic disease of the heart, (§ 2S9,) when 
the kidneys are otherwise healthy. 2. I have, in a few instances, 
observed temporary albuminuria during the congestive stage of 
eruptive fevers. 3. In granular degeneration of the kidney, the 
amount of albumen in the urine is augmented by circumstances 



CONGESTION SYMPTOMS AND EFFECTS. 161 

causing congestion of the kidney, and is reduced by remedies 
suited to remove this. 4. Bright's disease of the kidney, in its 
earliest stage, presents the appearance of a highly congested 
structure, and is excited by causes calculated to produce conges- 
tion, such as frequent irritation of the kidneys by stimulating 
liquors — congestion from exhausted tone, (§ 294;) continued ex- 
posure to cold, especially after the kidneys have been thus excited 
— congestion from intropulsion, (§ 292:) scarlatina probably ope- 
rates as the two last combined. 5. The albumen in the urine 
abounds most in the congestive (first) stage of Bright's disease 
— the vessels becoming more or less obliterated in the progress 
of the disease by a deposit of lymph (§ 307) in the cortical sub- 
stance, and perhaps, especially in the corpora malpighiana — 
which deposit is, at the same time, the cause which perpetuates 
some degree of congestion, whilst it supersedes the proper secret- 
ing structure.* 

310. From what has just been stated, it may be inferred that 
congestion, if continued, may affect the nutrition and structure 
of textures. It generally tends to cause an increased deposit in 
them, constituting a variety of hypertrophy. Thus, with diseases 
of the heart which cause congestion, there is an increase in the 
weight of the viscera generally, more particularly the lungs and 
liver. (Clendinning.) The enlargement of the liver and the spleen 
from long attacks of intermittent fever (called ague-cakes) may 
probably be referred to the congestion which this disease is known 
to induce, (§ 293.) I have known a similar enlargement of these 
organs to ensue after long continued exposure to cold and damp, 
(§ 77, 292.) 

311. But the hypertrophy resulting from congestion is proba- 
bly not of a uniform kind, comprising equal growth of all the 
textures; but, arising from an effusion of lymph from the most 

* The secreting structure is partly diminished in another way also. The 
granular deposit presses not only on the blood-vessels, but on the uriniferous tu- 
buli also; and wherever it totally obstructs them, their office ceases. These 
tubuli becoming distended, form the serous cysts so commonly found in granular 
kidneys, and sometimes in those which are not granular. But these cysts contain 
serum, or a gelatinous fluid, not urine; and this fact has been urged against the 
notion that they are dilated uriniferous tubes. The explanation, however, is not 
difficult. The secreting function of the kidney lies in nucleated cells lining the 
tubuli, (Bowman;) growing, filling, and bursting, as these cells do, by imbibition 
from adjoining vessels, this process, which is that of secretion, must be stopped 
when the cells are themselves pressed on by an accumulation of their own se- 
cretion, which cannot escape; but a serous exhalation from the blood-vessels 
still goes on, displacing by endosmosis the urine, and at last distending the duct 
mi" ;i <-yst. The same explanation will apply to the serous cysts of the liver. 
This view explains how retention of urine or bile may lead to the suppression of 
the secreting power. 

14* 



162 PROXIMATE ELEMENTS OF DISEASE. 

congested vessels, it is an intervascular deposit — at first mottling 
and exaggerating the appearance of the natural structure, as seen 
in the nutmeg liver and in the early, soft stage of granular dege- 
neration of the kidney — afterwards contracting and compressing 
the natural structure, and ultimately causing its condensation and 
atrophy, whilst the new deposit itself forms a granular or nodu- 
lated texture of low vitality, (§ 211.) 

312. Such I believe to be the nature and origin of cirrhosis of 
the liver, and granular degeneration of the kidney. The varie- 
ties which these structural diseases present may often be traced 
to their degree of advancement, or to the extent to which they 
involve the structures; and an argument in favour of their origin 
in congestion may be found in the fact that they are commonly 
more advanced and extensive in the most dependent parts of the 
organs; as the lower margins of the liver, where congestion is 
most promoted, (§ 2.90.) It is highly probable, also, that these 
plastic products of congestion arc in some cases, more or less 
developed and further modified by determination of blood or 
inflammation, and by the composition of the blood itself. 

Long continued congestion in the lungs may cause hyper- 
trophy of the intervesicular and interlobular texture, and in 
some cases, partial consolidation of the vesicular structure itself. 
Such changes are frequently met with in connection with long 
standing disease of the heart, and abound most in the posterior 
parts of the lungs, and near their roots, the most vascular 
parts. In the membranes of the brain, and in the capsules of 
the heart, liver, and spleen, opaque thickening is often seen 
along the course of the blood-vessels, especially of the veins, ap- 
parently the result of the overflow of nutritive matter from these 
vessels. 

REMEDIES FOR CONGESTION'. 

313. The most important means in the removal of congestion 
are those which contribute to the removal of their causes. Thus 
the loosening of a ligature, or the reduction of a tumour, com- 
pressing veins; the moderating the inordinate and inefficient 
action of a diseased heart; the restoration of the secretion of the 
liver, (§ 172,) — will severally tend to diminish the congestions 
resulting from these different venous obstructions. 

314. So, also, in the treatment of congestion from atony or 
weakness of the capillaries, it is important to remove the cir- 
cumstances which have caused this atony. In many cases it is 
over-distension from gravitation, (§ 296;) here change of posture 
gives relief. Thus, in congestive fevers, it is useful to change 



CONGESTION — REMEDIES. 163 

from time to time the position of the patient. With congestion 
of the head, this part should be supported high. The recum- 
bent posture gives much relief to congested hemorrhoidal or ute- ' 
rine vessels, as we see it reduce the swelling of varicose limbs. 

Pressure is sometimes a remedy for congestion, by supporting 
the weak vessels and promoting their contraction. This forms a 
chief part of the useful operation of bandages, adhesive plasters, 
and even of poultices, in various external congestions. It proba- 
bly might be more extensively applied to these, and even to some 
internal congestions, in the modes suggested by Dr. Arnott, by 
mercury, or by the slack air-cushion. 

Friction is a modification of pressure especially suitable to 
some forms of congestion, being calculated to give the motion 
that is defective, as well as to support the weak vessels. It is 
obviously useful in external congestions from cold; and some- 
times in visceral congestions, as those of the liver and abdomen 
generally. Exercise operates somewhat in the same way. 

315. Another class of remedies for congestion comprehends 
those which promote the contraction of the dilated vessels by 
augmenting their contractility or tone, (§ 124.) In this way 
astringents and cold operate; as in the use of solutions of alum, 
sulphates of zinc or copper, acetates of zinc or lead, and in- 
fusion or decoction of oak bark, catechu, kino, nutgalls, &c, in 
various congestions, particularly of the conjunctiva, throat, rec- 
tum, and vagina. The most obvious part of the action of bark, 
quinine, and arsenic, in the cure of ague, is in their reducing the 
great visceral congestions, which form their most remarkable, and 
perhaps their most important pathological element. 

316. The utility of astringents in congestion is limited by the 
fact, visible under the microscope, that they commonly contract 
the arteries more in proportion than the capillaries and veins, 
which are most distended. Hence they may still further impair 
the motion of the blood, and increase the congestion. A re- 
action, however, sometimes occurs, which converts the opera- 
tion of the astringent into that of a stimulant, which is another 
kind of remedy for congestion. The same remark is applicable 
to cold; and even more so, inasmuch as it also causes a physical 
obstruction to the flow of blood, in the manner formerly de- 
scribed, (§ 296.) 

Stimulants sometimes are remarkably effectual in removing 
congestions. Thus diluted spirit to a congested conjunctiva, 
capsicum to a congested throat, a stimulating wash or ointment 
to a purple sore or surface, will often signally reduce the con- 
gestion. Other congestions are removed by exciting the circu- 
lation generally; a stimulant draught, or even one of any hot 



164 PROXIMATE ELEMENTS OF DISEASE. 

liquid, relieves the pulmonary congestion which has induced a 
fit of asthma; a congestive headache is sometimes mitigated by- 
similar means. Well regulated exercise tends to disperse con- 
gestions in various parts. Various agents, which specifically ex- 
cite particular organs or parts, (§ 173,) are often useful in remov- 
ing congestions from them. Thus mercury is, in some cases, a 
remedy for a congested liver; some diuretics, as digitalis and can- 
tharides for congested kidneys; squill, benzoin, and other expec- 
torants, for bronchial congestion. 

317. The influence of stimulants on congestion may be illus- 
trated by the microscope. A solution .of capsicum applied to a 
frog's web, congested after previous irritation, causes an enlarge- 
ment of the arteries, and an increased flow of blood to and 
through the congested vessels. This flow restores motion where 
it was deficient, sweeps away the accumulated blood, and, in 
some instances, causes the vessels to contract afterwards to their 
natural size; so that the congestion is completely removed. In 
some cases, however, the stimulus fails to clear the congested 
vessels; the enlarged arteries pour in more blood; but this not 
overcoming the obstruction, increases the congestion, and, as we 
shall afterwards see, may convert it into inflammation. Thus 
both stimulants and astringents, although occasionally remedies 
for congestion, sometimes tend to increase it; and this they are 
most likely to do when the congestion is great or of long continu- 
ance, or when its causes are still in operation. 

318. Under such circumstances, congestion is better relieved 
by another class of remedies, depletion, and various evacuants. 
Blood-letting, by puncture or incision in the congested parts, 
enables the distended vessels to unload themselves, and they may 
recover their size; and the utility of this expedient is shown in 
scarifications of congested conjunctivae and tonsils. But the blood 
is more usually drawn from the vicinity of the congested part, as 
by cupping, or leeches on the chest or side for congested lungs or 
liver;* to the sacrum for congested uterus; or by leeches to the 
anus for congested intestines. Or, without actually shedding the 
blood, it may be drawn away from the congested part by deriva- 
tion; that is, by agents which cause determination of blood or 
congestion in other parts; as dry cupping, mustard poultices, and 
other stimulating applications to the surface, and by purgatives 
and other evacuants from the interior. 

* It is remarkable how quickly congestions may be reduced by these means. 
I have known a congested liver, which reached from the umbilicus to the lburth 
right rib, (as traced by percussion,) reduced in twelve hours to its normal di- 
mensions by cupping and free purging. Piorry describes a still more speedy 
reduction of the liver in ague, by the influence of the sulphate of quinine 



DETERMINATION" OF BLOOD. 165 

319. The operation of several of the foregoing agents, in com- 
bination or succession, is generally more effectual than that of 
single ones in the cure of congestions. Thus congestion of the 
liver may resist the action of mercury, and may even be aggra- 
vated by it, (§ 294,) until the vascular distension has been par- 
tially reduced by local blood-letting or derivants; then the mercury, 
by increasing the secretion, reduces the' remaining congestion. 
Congestion of the kidneys is augmented rather than diminished 
by diuretics, which then fail to increase the secretion of urine, 
but may only render it more albuminous, (§ 304.) But after some 
relief has been given by cupping to the loins, and hydragogue 
purgatives and diaphoretics, then some diuretics, particularly 
digitalis and cantharides, cause a freer flow of. urine with less 
albumen. The same point might be further exemplified; but it 
is unnecessary to multiply instances. 

320. The cause of congestion being, in many instances, atony 
of the vessels, (§ 290,) it .may often be counteracted by circum- 
stances which augment the tone of the vessels, locally or gene- 
rally. Thus cold, astringent, or, occasionally, stimulant applica- 
tions, by bracing the fibres and invigorating the circulation in a 
part, (§ 124,) render it less liable to congestion from disease; and 
general tonic measures operate in a similar way on the whole 
system. Probably the efficacy of bark and arsenic in preventing, 
as well as in removing internal congestions in ague, depends on 
their power of augmenting the tone of the vessels of these parts, 
(§315.) A similar virtue seems to be possessed, in some degree, 
by iodine and its preparations, especially the iodide of potassium; 
under the use of which the disposition to local congestions is di- 
minished, and those formed are sometimes dispersed. Mineral 
acids and other tonics have a like effect in cases of general 
weakness. Tbe treatment calculated to remove the results of 
congestion will be considered under the subjects, Flux, Dropsy, 
and Inflammation. 



SECTION V. 

LOCAL HYPEREMIA— EXCESS" OF BLOOD IN A 
PART. 

II. WITH MOTION INCREASED — DETERMINATION OF BLOOD. 

321. Numerous examples of this kind of active hyperaemia are 

presented in health as well as in disease. Blushing, the growth 



166 PROXIMATE ELEMENTS OF DISEASE. 

of the stag's antlers, and the uterus and breasts at the periods of 
gestation and lactation, furnish instances occurring in health. 
The increased number and size of the blood-vessels, manifest by 
the vascular redness in these cases, show the increased quantity 
of blood in the part; and the stronger pulsation of the arteries 
leading to the part indicates the augmented motion of that blood, 
(§ 2740 

322. In disease we meet with many examples. Determination 
to the head is one familiarly known; and it affords the opportu- 
nity of displaying one of the characteristics of determination, in 
the enlargement and throbbing of the carotid arteries. I have 
witnessed this phenomenon in a great variety of cases. One 
patient was subject to attacks of determination of blood, which 
caused him so much suffering and loss of moral control, that he 
cut his throat to destroy his life. When recovering from the 
wound, attacks sometimes came on; first with beating of the 
carotids, then flushing of the face and head, suffusion of the eyes, 
and sensations of distraction in the head. In the slighter attacks, 
these symptoms would all pass away in a minute or two. I have, 
in several cases, observed the same symptoms usher in the par- 
oxysms of mania. 

323. Fits of epilepsy and convulsive hysteria arc immediately 
preceded by throbbing of the carotids, which shows that deter- 
mination of blood is the proximate cause of the paroxysm. Drs. 
Darwin and Parry relate cases in which convulsive fits were pre- 
vented by pressure on one of the carotids; and 1 have practised 
this expedient with success in several instances. Many of the 
epileptic patients whom I have questioned have stated that the 
fit is always preceded by palpitation, which, for reasons before 
explained, (§ 266,) sometimes peculiarly determines blood to the 
head. But without the patient being conscious of palpitation, 
there maybe determination of blood to the head; and in numer- 
ous observations, I have found this to be so commonly present, 
that I believe it to be the common immediate cause of the sudden 
paroxysms of various kinds of disorder which affect the nervous 
centres. Infantile and puerperal convulsions are probably to be 
included in this remark, although they may be connected with 
very different conditions of the vascular system in point of fulness. 

324. But the most common cases of determination of blood 
are those caused by the application of stimuli. Thus heat causes 
a flow of blood to the surface; snuff, to the nose and eyes; spices 
in the mouth, to the salivary glands; food in the stomach, to its 
secernent vessels; purgatives, to the vessels of the intestines, and 
those of glands connected with them; diuretics, to - those of the 
kidneys, &c. &c. In fact, in the operation of most medicines, 



DETERMINATION OF THE BLOOD. 167 

there is an increased flow of blood to particular organs or sur- 
faces; and there are few diseases unconnected with local deter- 
mination of blood. We shall find hereafter that it occurs in 
inflammation as a part of that complex process; but Dr. Parry 
was wrong in supposing that inflammation consisted in this 
alone. 

325. Now, what is the physical cause of determination of 
blood? In some cases, increased action of the heart (§ 112) may 
propel the blood with unusual force and quantity to the arteries 
in its immediate vicinity, (§ 266;) and thus determination of blood 
to the lungs, the neck, and head, is a common result of inordinate 
action of the heart. But in many of the examples above cited, 
(§ 323, 324,) local determination takes place without any increase 
of the heart's action. 

Is determination of blood caused by increased action of the 
arteries? The only active property which we know these vessels 
to possess is that of slow or tonic contraction, (§ 120;) and such 
contraction of arteries leading to a part would diminish instead 
of increasing the motion and quantity of blood proceeding to the 
part, (§ 294.) 

326. We may answer, from direct observation as well as from 
reasoning, that determination of blood is effected by enlargement 
of the arteries; and this enlargement is the effect of the pressure 
of the arterial distension from behind acting on a tube which has 
lost some of its contractile power, (§ 120.) The tonicity of the 
arteries makes them naturally resist the distending influence of 
the mass of blood pumped into them by the heart; but if this 
tonicity be impaired in any part, that of other parts forces the 
blood in augmented quantity into it, by which it is distended, and 
becomes an enlarged channel for the transmission of more blood 
and more force, (§ 323.) If the arteries are enlarged, the capil- 
laries and veins leading from them will be also enlarged, and will 
share the increase of blood and motion thus supplied to them, 
(§ 298, note.) We find the proof of the enlargement and dis- 
tension of arteries leading to an inflamed or irritated part in their 
increased and harder pulse; the coats of the vessels being stretched 
to tightness, the pulse is no longer softened by the usual elastic 
spring. 

So, too, in the frog's web gently irritated by an aromatic water, 
we see the arteries become enlarged, supplying a larger and more 
rapid flow of blood to the capillaries and veins, which all become 
enlarged, also; and the whole vascular plexus, including vessels 
which before scarcely admitted red particles, then become the 



168 



PROXIMATE ELEMENTS OF DISEASE. 



channels of a much increased current. This is determination of 
blood. * 

327. There appears, then, to be ho difficulty in tracing local 
determination of blood to its physical cause, enlargement of the 
arteries leading to the affected part. But it is not equally easy 
to find a physiological explanation of the cause of this enlarge- 
ment. The terms " active dilatation" (Hunter) and " vital tur- 
gescence" (Kaltenbrunner) have been applied to the condition 
in question; but all that is known of animal physics is. opposed 
to the possibility of there being a power of active dilatation in 
the arteries. 

The physiological condition seems to be a weakening or reduc- 
tion of the tone (§ 123) of the artery; so that it becomes passively 
distended by the vis a tergo. In some cases, it might be supposed 
that this weakness is the result of previous stimulation, (§ 116;) 
and it has been stated above that a momentary contraction of 
the artery precedes its dilatation. But the dilatation is out of all 
proportion to the previous contraction; and, in some cases, as in 



Fig. 1. * As these phenomena have not been 

distinctly described by observers apart 
from the further effects resulting from 
over-irritation, which leads to obstruction 
and inflammation, I will state shortly 
some results of many observations on the 
circulation of the frog's web, under the 
influence of moderate stimuli applied to 
it. These observations were made in the 
summer of 1841, and some of them are 
mentioned in my Gulstonian Lectures, 
published in the Medical Gazette of July 
1841. 

The arteries may be distinguished from 
the veins in the frog's web, not only by 
the direction of their current and its 
greater rapidity and transparency, but 
also by a series of lines along their 
course, marking the size to which they 
have been distended at some previous 
time. (See A, Fig. 1.) These lines or 
channelings are most distinct, and are 
more remote from the artery at its angles 
or bifurcations. They are to be seen some- 
times along the veins, but much less dis- 
tinctly. Now these lines are in them- 
selves proofs of the varying distension 
of the arteries, and they also furnish the 
means of measuring this, varying dis- 
tension. 

When a weak infusion of capsicum is 
applied by a camel's hair pencil to the 
web, there is a momentary retardation of the current in the veins, and the artery 
distinctly shrinks in size. But in a few seconds the reverse takes place; the 




DETERMINATION OF BLOOD. 



169 



blushing and the growth of parts, there is no sign of any pre- 
vious contraction. 

Dr. Billing ingeniously conceives that, by stimulating the nerves, 
the nervous influence is drawn away from the vessels; and that 
their contractility, being derived from this influence, is thus im- 
paired. But besides other objectionable points, this view as- 
sumes that muscular irritability, even its lowest form, tonicity, 
is a property derived from the nerves — an assumption unwar- 
ranted by the facts and opinions most generally received by 
physiologists, (§ 110.) 

328. There can be little doubt that the nerves — especially the 
sympathetic (§ 152) — are sometimes concerned in causing deter- 
minations of blood; and it is not improbable that their influence 
is that of reducing the contractility of particular arteries, just as 
strong moral emotions, acting through the nerves, paralyze the 
sphincters and muscles of voluntary motion, (§ 144, 154.) But 



artery swells to beyond its former size, and reaches the utmost line of its chan- 
nel; the flow of blood through it is too rapid to be distinguished, and all the capil- 
laries present a scene of busy motion; Fig. 2. 
in some the particles passing in num- 
bers and speed greater than the eye 
can appreciate; in others, before invi- 
sible, single files force their way in 
more deliberate, but continuous 'mo- 
tion; whilst in the veins the movement 
is again more rapid. This motion 
begins to flag, and becomes remittent 
or oscillatory in some capillaries; and 
it is seen that the arteries have already 
begun to shrink in size, and the chan- 
nelled lines which they had reached 
reappear. Sometimes, in shrinking, 
the artery assumes for a time a more 
tortuous shape than before, (as in Fig. 
2;) so that its walls cease to be paral- 
lel with the lines, which seem to show 
that it contracts in diameter before its 
length is proportionally reduced. The 
contraction of the artery, and conse- 
quent reduction of the quantity and 
movement of the blood in the vascular 
plexus, was promoted by repeated ap- 
plications of cold water, (§ 124,) which 
in some instances stopped the motion 
of the blood, altogether, by contracting 
the artery to so small a size, that no 
blood particles entered it. A solution 
of acetate of lead also produced this 
effect. 

The determination of blood thus ex- 
cited produces an increased redness quite visible to the naked eye; but it is less 
intense, and more florid than the redness of inflammation or congestion. 




170 PROXIMATE ELEMENTS OF DISEASE. 

the laws of tonticity, and its relation to the nervous influence, 
require further investigation. 

329. We can see something of the final cause of determination 
of blood. " Ubi stimulus, ibi fluxus." The flow is intended to 
support the well-being and function of the part. If any influence 
disturb its well being, or excite its function, more blood is wanted: 
the arteries dilate to supply more and in greater force, and thus 
the circulation through the part is augmented. The result is, in 
moderation, to increase the redness, warmth, sensibility, secre- 
tion, nutrition, and other functions of the part; in excess, to dis- 
order and alter them. 

330. We have hitherto considered local determination of blood 
as resulting from causes which directly affect that part of the vas- 
cular system in which the determination takes place. In not a 
few cases, however, the same result arises from opposite causes, 
acting on other parts of the vascular system. Thus as we found 
external cold cause external congestions by intropulsion, (§ 292,) 
so too it may occasion internal determinations of blood. 13y con- 
stricting the vessels of the surface and extremities, it directs the 
force as well as the quantity of the circulating fluid on internal 
parts, or those beyond its influence. Thus, in many persons cold 
weather causes palpitation, dyspnoea, pain in the chest, throbbing 
and pain in the head, gastralgia, colic, and fluxes of various kinds, 
whilst the extremities are cold, the surface chilly, and the radial 
pulse very small, even when the heart beats with great force. 
It is obvious that in such cases this force is expended chiefly on 
internal organs, which thus become the seat of" determination of 
blood. 

The subjects in whom cold causes internal determinations of 
blood, are chiefly those endowed with much irritability, (§ 113,) 
but little blood, (§ 2G1.) The same persons likewise are liable 
to a flush of blood to the face and head, with coldness of the feet, 
when they go into a warm room. By cooling the head, the feet 
become warm; or by warming the feet, the head cools. 

331. Attacks of local determination of blood from other causes 
are often accompanied by shivering fits, pallidity, coldness of the 
extremities and defective secretions, particularly in persons of 
weak circulation. When an unusual quantity and force of blood 
is determined to one part, there must be less in other parts, which 
therefore suffer from the deficient supply. This furnishes an 
important therapeutic indication, to be noticed hereafter. 

332. As we find determination of blood to be chiefly produced 
by an enlargement of some arteries from a reduction of their 
tonic power, (§ 326,) so we may be led to expect that such en- 
largement may affect any part of the arterial system. We have 
chiefly considered it in relation to the distribution of blood to 



DETERMINATION OF BLOOD. 171 

parts; but it may also occur in the great arterial trunks. Inor- 
dinate pulsation of the aorta, especially in the abdomen at the 
cosliac axis, or at the bifurcation into "the iliacs, (corresponding 
with a little below the epigastrium and umbilicus,) is a common 
symptom in nervous subjects. Epigastric pulsation I have found 
frequently before and after hsematemesis. In one case, hagmaturia 
and lithic deposits in the urine occurred in a woman affected with 
strong pulsation at the umbilicus. 

SYMPTOMS AND EFFECTS OF DETERMINATION OF BLOOD. 

333. Many of the symptoms of determination of blood may 
be learned from the preceding illustrations. It generally exalts 
contractility, (§ 112,) sensibility, (§ 126,) and other nervous pro- 
perties (§ 149) of the part, causing spasm, pain, irritation, and 
sympathetic disorder. In its moderate degrees, it increases the 
natural secretions of the part, (§ 162,) and thus becomes the 
cause of mucous, bilious, and urinary fluxes, &c. The nutritive 
function is likewise increased, and more naturally than from con- 
gestion, the result being a more simple and general hypertrophy 
of the part. The process of absorption, although favoured when 
the current is accelerated without distension, is often not equal to 
the effusion. Hence in sacs and cells determination of blood 
may cause dropsy. 

A few examples will suffice to illustrate the symptoms and 
effects of determination of blood. 

334. The parts most subject to determination of blood are 
those most freely supplied with blood-vessels, (§ 30,) as the brain, 
the parenchyma of glands, mucous membranes, and the skin. 

335. Determination of blood to the head often takes place in 
some persons from mental excitement, violent exertion, stimulant 
drinks, or defective excretion. The symptoms vary considerably; 
but increased beating of the carotid and temporal arteries, some 
flushing of the face and suffusion of the eyes, and an increase of 
the symptoms on stooping, or lying with the head low, are com- 
monly perceptible in all cases. The other symptoms are some- 
tin n s those of simple excitement of the nervous centres, painful 
throbbing in the head, excessive sensibility to light and sound, 
flashes in the eyes, noises in the ears, an excited state of the 
mind, rapid flow of ideas, sometimes bordering on delirium, 
wakefulness or dreamy sleep, restlessness and irritability of tem- 
per. Sometimes these symptoms arc replaced by others indi- 
cating a temporary oppression of nervous functions, such as gid- 
diness, drowsiness, stupor, imperfect vision and hearing, with 
apparenl specks ot mist in the eyes., impaired articulation, and 
power of locomotion, occasionally with various convulsive affec- 
tions, as m hysteria and epilepsy. 



172 PROXIMATE ELEMENTS OF DISEASE. 

336. It may seem difficult to explain how such opposite symp- 
toms, those of excitement and those of oppression, are produced 
by the same cause — determination of blood. But the explana- 
tion is readily found on referring to the true nature of determina- 
tion, and the different modes in which it affects the circulation 
within the head. Moderate excitement of the brain, as by bodily 
exercise, mental exertion, or certain beverages, such as tea and 
coffee, is accompanied by increased but equal flow of blood 
through the brain. But if these or other causes of excitement 
operate in excess, the arteries supplying the brain are still fur- 
ther dilated, and convey blood to it with more force without an 
equal increase in the passage of the blood through it; and this 
for two reasons. 1. We have already found that a certain pro- 
portion in the size and elasticity of the vessels best qualifies them 
to transmit blood freely, (§ 301;) and that where this is wanting, 
increased force does not compensate for it, but often causes new 
disorder. Thus in violent palpitation of the heart, the aorta, 
carotid, and subclavian arteries are often dilated, and throb 
strongly; but the weak pulse at the wrist shows that much force 
is expended on the larger trunks, without reaching their distant 
branches. This too is one reason why, in determination of blood 
to the head, the force is sometimes more expended in the larger 
vessels at the base of the brain than transmitted throughout its 
substance. 2. Another reason for unequal or defective excite- 
ment from determination of blood to the head, is the unyielding 
nature of the skull, which permits no considerable enlargement 
of any of the vessels within it, without a corresponding diminu- 
tion of other vessels, and a general compression of the cerebral 
substance. Hence distension of the arteries beyond a certain de- 
gree, will compress and obstruct the small veins, and thus pre- 
vent that freedom of circulation on which functional activity 
depends. On these principles may be explained the production 
of symptoms of depressed as well as excited energy of the nerv- 
ous centres, and often a mixture of both, from the same cause, 
determination of blood, (§ 153.) 

337. Determination of blood to the kidneys is caused by stimu- 
lating diuretic drmks, and besides the increased flow of urine, 
may produce pain in the loins and throbbing in the abdominal 
aorta. Excitement of the circulation, by exercise or by nervous 
affections, also reaches the kidneys; exercise carries off much 
fluid by the skin; but nervous excitement, where it fails to cause 
perspiration, determines more to the kidneys, and this seems to 
be the source of the abundant flow of limpid urine which follows 
convulsive and other nervous affections. 

338. Determination of blood to mucous membranes is exem- 
plified in certain forms of dyspepsia, in which sudden pain, or 



DETERMINATION OF BLOOD REMEDIES. 173 

heat, or nausea, is felt in the stomach, accompanied by epigastric 
pulsation, and sometimes followed by eructation of sour or other 
liquid, and sometimes by haematemesis. These attacks are often 
induced by excitement, general, or local, from irritant ingesta. 

339. Determination of blood to the skin is often produced, not 
only by direct irritation, but from the influence of internal causes; 
as in case of blushing from mental emotion, flushing of the face, 
from acid in the stomach, and the general redness of the surface 
in reaction after cold, or at the commencement of fevers. In va- 
rious chronic skin-diseases the'eflect of determination is seen in a 
brightening of the colour of the eruption, which may take place 
in a few minutes. 

340. Determinations of blood are often transient, coming on 
suddenly and soon subsiding. When they are more permanent, 
they commonly lead to other disorders. In their immediate seat 
they cause either increased secretion, with the addition of more or 
less of the watery, saline, and albuminous parts of the blood, or 
haemorrhage, or they may pass into inflammation. In other parts 
of the body, there is often, at first, coldness, and defective circu- 
lation and "function, (§ 330,) but afterwards there often succeeds 
a febrile reaction, with hot skin, accelerated pulse, scanty secre- 
tions, and other symptoms of inflammatory fever. 

341. The frequent recurrence of determination of blood, or its 
long continuance in a lower degree, affects the structure; increased 
nutrition, hypertrophy, being the result. This may be a natural 
kind of hypertrophy, as in the case of muscles, which increase 
in size in proportion to their exercise, which increases the circu- 
lation of blood through them. So the uniform hypertrophy of 
the substance of the heart, and of other organs, after long con- 
tinued excitement of that organ, may be referred to the increased 
determination of blood that has been kept up. In other cases 
parenchymata, as those of the kidneys and liver, exhibit altera- 
tions rather than mere growth; and albuminous deposits and 
granular degeneration result. In these and other cases the effect 
on the structure is commonly modified by the occasional presence 
of congestion, inflammation, and the plastic condition of the blood 
itself, (§211.) 

It is unnecessary to dwell further on the phenomena and results 
of determination of blood, as we shall have to advert to them in 
connection with its occasional results — flux and haemorrhage, 
and with inflammation, of which it is a component part. 

REMEDIES FOR DETERMINATION OF BLOOD. 

342. In the treatment of all cases of determination of blood, as 
of diseases in general, it is obviously proper, as much as possible, 

15* 



174 PROXIMATE ELEMENTS OP DISEASE. 

to remove the exciting causes. Thus in the numerous class of 
cases arising from the action of stimuli or irritants on the part 
which is the seat of the determination, (§ 324,) the removal of 
such irritants, or the diminution of their action by soothing or 
diluent remedies, is a first indication. 

343. If we are correct in tracing local determinations of blood 
chiefly to an atonic distension of the arteries supplying the part, 
(§ 326,) we may expect measures which promote their contraction 
to be efficient remedies. This is the fact; for cold is one of the 
most effectual means which we possess, in subduing determina- 
tions of blood; and this was mentioned as a chief remedy for the 
element, defective tone, (§ 124.) Astringent applications are 
ecmally useful in some instances of local determination; as in the 
application of solutions of acetate of lead, sulphates of zinc and 
copper, nitrate of silver, and other astringent lotions to external 
surfaces, (§ 326, note;) but these are chiefly useful where the de- 
termination is quite local and unconnected with generally in- 
creased circulation, otherwise they become irritants rather than 
astringents, (§ 317.) But besides cold and other astringents to 
the part which is the seat of the determination, and to the arteries 
leading to it, derivanls, or means which draw away blood by 
relaxing other parts of the vascular system, are especially indi- 
cated by many preceding observations, (§ 330, 331, 340.) Of 
these derivants, heat is the most effectual, especially when com- 
bined with moisture. 

344. Thus cold lotions or douche to the head, and the hot 
footbath, are among the best remedies for determination to the 
head. Taking copious draughts of cold water, or more sparingly 
of iced water, will often relieve epigastric pulsation and palpi- 
tation of the heart. The warm bath, by deriving to the surface, 
will diminish the flow of blood to the kidneys. I have known 
severe nephralgia instantly relieved by cold affusion on the loins; 
but the practice is too hazardous to be recommended. 

345. Various evacuant remedies may also be employed to 
counteract determination of blood, by determining a flow in 
another direction; and thus purgatives, diuretics, and diapho- 
retics, are often useful. Of these, purgatives are by far the most 
powerful and sure in their operation, and of great efficacy in de- 
terminations to the head. Change of posture, by elevating the 
part which is the seat of determination, may sometimes be use- 
fully practised. 

346. But the most powerful derivant is blood-letting, general or 
local. By the microscope it may be seen how opening a blood- 
vessel changes the currents of blood; the currents of many ves- 
sels are reversed and drawn towards the bleeding point, whilst 
in others they are retarded where they were before running with 



DETERMINATION OF BLOOD — REMEDIES. 175 

great speed. But blood-letting is unnecessary and injurious in 
many cases of determination of blood, especially those attended 
with a deficiency of blood in the whole system; and, as we have 
seen, such cases are not rare, (§ 330.) Dry cupping is a good 
substitute in some instances; but even this measure is more 
weakening than it is generally supposed to be, for much blood 
being extravasated into the skin and cellular texture, is really 
lost to the system, as blood — its particles are changed, and their 
structure destroyed. 

The cases in which blood-letting should be used are those 
where determination to an important organ is combined with 
some general plethora or local congestion, or has continued so 
long as to threaten a termination in inflammation. A speedy 
blood-drawing, as by cupping or free venesection, will generally 
answer best. 

347. In the same class of cases, certain remedies are useful 
which seem to cause a general relaxation of the tonic fibres 
(§ 122) of the vascular system, and an equalization of the force 
and blood which this system conveys, (§ 331.) Antimony is the 
chief of these; and it is most indicated where febrile reaction has 
begun. 

348. Another class of remedies suitable for determination of 
blood, attended with much excitement, are sedatives, or those 
which reduce the heart's action, (§ 115,) such as digitalis, hydro- 
cyanic acid, and nitre. These are chiefly useful where the de- 
termination occurs in connection with palpitation, as in the case 
of the various convulsive or other sudden nervous attacks 
which I have proved to be so commonly excited by palpitation, 
(§ 322-3.) I have entirely cured several cases of convulsive 
hysteria, and much reduced the frequency of the fits in epilepsy, 
by these remedies, sometimes combined with cold affusion on 
the head in the morning, and the hot footbath at night, (§ 331.) 
Hydrocyanic acid probably operates chiefly on the organic ex- 
citoinotory nerves, and by lowering their function prevents the 
undue excitement which they communicate to the heart. In this 
respect it surpasses conium and hyoscyamus, which are also some- 
times useful in preventing determination of blood arising from 
nervous excitement. 

349. We have found (§ 330) that in many instances determi- 
nation of blood to internal organs results from weakness of the 
circulation, and especially a want of tone in the whole vascular 
system, (§ 123;) so that under the operation of cold constricting 
the external vessels, or irritations exciting interna] organs, the 
latter monopolize most of the blood and force of the heart's 
action. In such cases, besides temporary means to equalize the 
circulation, (heat to the extremities and surface, cold and astrin- 



176 PROXIMATE ELEMENTS OF DISEASE. 

gents to internal organs, gentle exercise, friction, &c.,) more per- 
manent remedies are to be sought in tonics, and various particu- 
lars in diet and regimen, which give strength to the contractile 
fibre, (§ 124,) and improve the quantity and quality of the blood, 
(§271.) 

Thus preparations of iron and bark are useful remedies in 
cases of the weaker kind; mineral acids, iodide of potassium, 
mild bitters, and the slighter metallic tonics, nitrate of silver, sul- 
phates of zinc and copper, are serviceable in others which will 
not bear the stronger tonics. In the use of any of these remedies 
it is necessary to guard against their exciting effects on the parts 
which are the seats of determination, by premising or conjoining 
the temporary remedies (§ 342, &c.) against that condition, and 
by keeping the secretions free and equally balanced. 

In all cases, country air, and exercise suited to the strength of 
the patient, and habits of posture opposed to the peculiar deter- 
mination, will be found useful in removing and preventing this 
morbid affection. 



SECTION VI. 
RESULTS OF HYPEREMIA. 

350. Before we proceed to the third and more complex variety 
of local hyperaemia, inflammation, we must notice some remark- 
able results to which the other varieties, when increased to a cer- 
tain degree, tend, when yet short of the conditions necessary to 
constitute inflammation — I mean, haemorrhage, flux, and dropsy. 
These results have been already mentioned as sometimes ensuing 
from plethora, congestion, and determination of blood, and in de- 
scribing haemorrhage, dropsy, and flux, it will be unnecessary to 
do more than exemplify their occurrence in connection with these 
proximate elements, and to trace the further peculiarities which 
distinguish each of these results. 

I. HEMORRHAGE. 

351. When in any form of hyperemia the blood-vessels are 
distended to a great degree, they sometimes give way and blood 
is effused. I shall give illustrations of the more common cases 
of haemorrhage proceeding from the kinds of hyperemia which 
have been already described. 

General plethora (§ 275) not unfrequently causes haemorrhage 
from the nose, {epistaxis,) from the stomach, (hasma/emesis, 
vomiting of blood,) from the rectum, (hasmo?'rhois,) and into or 
upon the brain, apoplexy. 



RESULTS OF HYPEREMIA — HEMORRHAGE. 177 

352. Congestion from venous obstruction (§ 289) produces 
haemorrhage in the cases of pulmonary apoplexy, (haemorrhage 
into the parenchyma of the lungs,) from obstructive disease of 
the left side of the heart; bronchial haemorrhage and haemoptysis 
(spitting of blood) from tubercles in the lungs; haematemesis and 
bleeding piles from obstructions of the liver, from disease, or 
violent straining. 

353. Congestion from iveakness of the vessels (§ 290) often 
causes haemorrhage in various dependent parts, in congestive 
fevers, and in various passive haemorrhages of weak subjects. A 
stooping posture has been known to cause cerebral hemorrhage, 
(apoplexy.) The erect posture may bring on uterine haemor- 
rhage, (§ 291.) 

354. The congestion of the head from the intropulsive opera- 
tion of cold (§ 292) sometimes leads to epistaxis and apoplexy; 
that from previous excitement of the stomach and kidneys in 
drunkards, (§ 294,) occasionally causes haematemesis and hsema- 
ticria, (bloody urine.) The congestion of the kidney in scarlatina 
is sometimes followed by haematuria. 

355. Haemorrhage, from determination of blood, (§ 322,) is 
exemplified in cases of epistaxis and apoplexy, preceded by in- 
creased beating of the carotids, flushing of the face, &c, (§ 335;) 
haematemesis from various irritants in the stomach, (§ 338;) hae- 
maturia from stimulant diuretics, (§ 337;) bloody dysentery from 
drastic purgatives, &c, (§324.) So also we shall find haemor- 
rhage to be a common concomitant or result of inflammation. 

35G. But all cases of general or local hyperaemia now noticed 
do not result in haemorrhage: some additional element is wanting; 
and this additional element may be either in the blood-vessels or 
in 1 1 h' blood. 

357. The blood-vessels are sometimes obviously in a diseased 
state. Inelastic and fragile, from osseous or atheromatous depo- 
sit, or aneurismal dilatation, the arteries of the brain become rup- 
tured under the influence of congestion or determination of blood. 
Softened and lacerable from inflammation or malnutrition, blood- 
vessels give way in various structures; and in this way haemor- 
rhage occurs from an inflamed stomach or colon, in tuberculated 
lungs, and in a diseased uterus. Sometimes actual ulceration 
opens an artery or vein, and this is not a very uncommon cause 
of haemorrhage in chronic ulceration, or malignant disease of the 
stomach, intestines, and uterus. Mechanical injury may rupture 
blood-vessels in the kidneys and nostrils: hence the haematuria 
and epistaxis which sometimes follow violent blows in the loins 
or on the nose. 

358. In other instances the huemorrhagic disposition can be 



178 PROXIMATE ELEMENTS OF DISEASE. 

traced to a peculiar state of the blood, which is defective in 
fibrin, (§ 196,) but abounding in red particles, (§ 18 1,) as in 
petechial fevers, congestive apoplexy, hemorrhagic small-pox, 
and other exanthemata. But there are other cases in which the 
disposition to haemorrhage prevails without any defect of fibrin 
or excess of red particles; scurvy and purpura are examples. In 
the former there is found to be the very reverse of these changes, 
(§ 185, 196.)* It appears probable that an alteration in the 
quality of the red particles (§ 186) and fibrin (§ 203) is the real 
evil in these diseases. The readiness with which textures be- 
come stained with the colouring matter, the purple, brownish, or 
particoloured stains left by inflammation, and, in extreme cases, 
the altered appearance of the blood itself, seem to show the 
colouring matter to be diseased; and the failure of the healing 
process, and the remarkably loose and bloodstained appearance 
of fibrinous coagula which form on the spongy gums, or in 
wounds, seem to indicate a want of vital plasticity in the fibrin, 
(§ 211.) Further microscopic observations are wanted on these 
subjects. 

359. Another question connected with haemorrhages relates to 
the mode in which the blood is effused. We have just seen that 
in some cases blood-vessels are distinctly ruptured, (§ 357.) But 
in other instances blood has been poured out in considerable 
quantities from various mucous surfaces, and even from the skin, 
without any discernible breach of vessels, or even of the surface. 
This statement has been made, particularly in regard to epistaxis, 
haematemesis, and some remarkable cases of hasmorrhage from 
the skin, occurring successively at different parts of the body. 
Considering the size of the red particles of the blood, and the 
absence of any visible pores in the walls of the blood-vessels, 
even under the highest magnifying powers, it does not appear 
possible that the particles can escape from the vessels without 
rupture either of the particles or of the vessels. At the same 
time, it may be stated that in the frog the red particles do pass 
through capillaries of caliber smaller than their short diameter; 
and in so passing I have often seen them rolled up in the manner 
of an ice-wafer. The appearances of capillary apoplexy, (cere- 
bral hasmorrhage,) and hasmorrhagic inflammations of serous 
membranes, countenance the opinion that many minute vessels 
become ruptured at once, probably in connection with an altered 
condition of the blood; and such minute ruptures occurring in 

* In acute hoemorrhagic purpura the fibrin is not deficient, for I have found 
the blood effused under the skin firmly coagulated. I have before mentioned 
my experience that purpura is generally connected with imperfect action of the 
liver, (§ 171.) 






HEMORRHAGE VARIETIES. 179 

membranes would not be discernible by common modes of ex- 
amination. 

VARIETIES OP HEMORRHAGE. 

360. Besides differences in seat, haemorrhages are distinguished 
into active or sthenic, and passive or asthenic; and the peculi- 
arities of these varieties may be traced to the same elements as 
the corresponding varieties of general and local hyperasmia, 
(§ 279,) excess and defect of the contractile power of the heart, 
(§ 110,) and of the tonicity of the arteries, (§ 120.) Thus haemor- 
rhages preceded or accompanied by the symptoms of sthenic 
plethora, (§ 280,) or with determination of blood, (§ 322,) are 
active or sthenic; whilst those occurring in connection with 
asthenic plethora, (§ 281,) or with mere congestion, (§ 287,) are 
passive or asthenic. We may therefore refer to the symptoms 
described under these subjects for the precursory symptoms of 
each kind of haemorrhage. 

301. But when the haemorrhage begins, it may modify the 
previous symptoms in various ways, besides the new local signs 
which the discharge of blood produces. In active haemorrhage, 
the full, hard pulse of sthenic plethora becomes modified by a 
remarkable jerk or thrill, which is an important symptom where 
haemorrhage is only suspected. I have noticed this thrill in the 
pulse even when the loss of blood has been very trifling, and 
where no murmur accompanies the heart sounds; and I am there- 
fore inclined to think that it depends on an unusual abruptness 
of the heart's contraction, (§ 113,) combined with irregularities in 
the tonicity of arteries in different parts, (§ 326, 332,) which 
cause these to react in successive jerks at each pulse, instead of 
simultaneously. In fact, this same thrill sometimes is felt during 
a paroxysm of determination of blood to a part without any 
haemorrhage resulting. 

361. If the quantity of blood effused be large, and especially 
if its loss be rapid, syncope, or various degrees of faintness and 
weakness, may ensue. The pulse becomes small, weak, and 
often irregular, the surface and lips pale; either consciousness, 
or the heart's action, may first fail, according to the posture of 
the patient, (§ 70,) and the condition of anaemia (§ 262) is in- 
duced. 

362. Even after this faint state has been induced, in the course 
of a few hours the increased action (reaction) returns; and it is 
under the influence of this thai the pulse exhibits the greatest de- 
gree of tin' jarring or vibratory character; so that it may feel like 
;i loose win' twanging, or a rough file drawn under the finger. 
Willi thisstate of the pulse, palpitation, throbbing of the great 



ISO PROXIMATE ELEMENTS OF DISEASE. 

arteries, and the various symptoms of partial nervous excitement 
described under the head of anaemia, sometimes occur, (§ 265.) 
During this reaction the haemorrhage may be renewed. 

363. If the haemorrhage is inconsiderable, or if it be suddenly 
checked by styptics before the vascular fulness or determination 
has been reduced, inflammation may ensue, with increasing 
strength and hardness of the pulse, heat of skin, and other 
symptoms of inflammatory fever. On the other hand, haemor- 
rhage to a considerable extent may remove the hyperaemia, and 
the various local and general symptoms of oppression, fulness, 
tightness, pain, and functional derangement which it had pro- 
duced. Thus we find headache and flushing often relieved by 
epistaxis; pain and oppression in the chest by haemoptysis; ab- 
dominal pain and pulsation by haematemesis, melaena, or haemor- 
rhoidal flux. 

364. But the blood effused may produce various disturbances 
and symptoms in the parts into which it is effused. Within the 
head it presses on the brain; and by interrupting the circulation 
through it, it may cause coma or paralysis, (§ 273;) or it may also 
break up the substance of the brain, and cause death by syncope 
(§ 116) and asphyxia combined. In the lungs, the blood may at 
once suffocate by its quantity, or cause dyspnoea and cough until 
it is expectorated. Here, too, it sometimes breaks up the texture of 
the lungs, leading to serious disorganization. In glands it forms 
swellings, or is mixed with, and modifies, their secretions, as in 
the case of hacmaturia. In other complete textures, it produces 
swelling, often followed by local inflammation; as instanced in 
the cutaneous swellings of purpura haemorrhagica. 

365. Passive or asthenic haemorrhage may be preceded by 
symptoms of asthenic plethora (§ 281) or congestion — maybe 
accompanied by symptoms of exhaustion if the loss is profuse, of 
relief it it be moderate; and anaemia may ensue from excessive 
loss; or reaction, sthenic haemorrhage, or inflammation, if the 
haemorrhage is too suddenly checked. The haemorrhage con- 
nected with an altered state of the blood is generally of the pas- 
sive kind, although excitement, or determination of blood, {mo- 
limen hsemorrhagicum,) sometimes comes on here also. 

TREATMENT OF HEMORRHAGE. 

366. As haemorrhage is commonly a result of plethora, con- 
gestion, or determination of blood, the remedies for these morbid 
elements will be more or less needed in its treatment. But the 
necessity for using these remedies will much depend on the ex- 
tent and seat of the haemorrhage, and the mischief likely to result 
from its continuance. For example: a moderate epistaxis or 






HEMORRHAGE — TREATMENT. . 181 

hemorrhoidal flux needs no -treatment: it is a natural cure for 
a previously existing hyperemia. But if these haemorrhages be 
profuse, whether of the sthenic or asthenic kind,. they must be. 
restrained: if sthenic, by. artificial bleeding, which is under con- 
trol, and by derivants to other parts, to reduce the fulness which 
causes the haemorrhage: if asthenic, by styptics, combined with 
derivants, to save the blood, the loss of which is injuring the 
system. ' ' • • • 

367. But in some cases, haemorrhage to. any amount may be 
injurious, and should be opposed from the first, both by reme- 
dies for the .hyperemia, which is the cause- -of the hemorrhage 
(§ 345, et seg.), and by -styptics, which peculiarly counteract this 
result. Thus hemorrhage from the lungs, or into the brain or 
other organ, requires prompt interference. The same rule may 
be applied to cases of excessive hemorrhage of any kind in all 
cases, and of more moderate hemorrhage in very weak subjects; 
in all of which the loss of blood is a pressing danger. • 

36S. In active hemorrhage, generally, blood-letting may be 
used until the • hemorrhage is arrested, or the p'ulse "reduced; 
and this effect should be sustained by other evacuants, especially 
purgatives, and diuretics. Remedies which diminish the power 
of the heart, such as digitalis, hydrocyanic acid, and nitre, in 
those which also reduce- the* tonicity of "the arteries, especially 
antimonial medicines, are likewise of great use in some active 
hemorrhages. An other powerful agent in hemorrhage, connected 
with increased action or determination. of blood, is cold, (§ 343.) 
Thus ice, or a stream of cold water on the nose and forehead in 
•case of epistaxis, ice swallowed in hematemesis, ice applied ex- 
ternally, or icy water injected, for uterine hemorrhage, is of con- 
siderable efficacy, (§ 344.) I do not approve of the practice 
recommended by some-, of applying ice to the chest, for hemop- 
tysis; I have seen pneumonia thus induced. 

The treatment of passive or asthenic hemorrhage, besides 
styptics to prevent excessive loss of blood, will include remedies 
for general plethora, (§ 216;) or local congestion, (§ 313, &c.)' which 
may cause the hemorrhage. Hence general or local depletion, 
derivants, accompanied or followed by tonics, may be useful. 

369. We have now to consider the means calculated to restrain 
all kinds of hemorrhage, and which is especially opposed to the 
causes which more immediately determine this result of disor- 
dered circulation, (§ 356.) If blood-vessels are softened, brittle, 
or actually ruptured or ulcerated, (§ 357,) a chief thing to be done 
is to diminish the quantity of blood sent to them; and, besides 
by blood-letting, this may be effected by pressure, posture, cold 
and :istiiii'_ r <'iit applications, and means calculated to tranquillize 
the whole circulation. Thus epistaxis is sometimes arrested by 
16 



182 PROXIMATE ELEMENTS OF DISEASE. 

pressure on the carotids; uterine haemorrhage by pressure on the 
abdominal aorta, or by elevating the pelvis; haemoptysis by keep- 
ing the chest high; and in all cases of haemorrhage, perfect still- 
ness and a cool regimen should be observed. 

370. The other pathological condition which favours haemor- 
rhage, the altered state of the blood, (§ 358,) is perhaps more 
directly influenced by the remedies called styptics. Most of these 
remedies are astringents, causing contraction of the tonic fibres 
of vessels and other parts, but some of them also coagulate the 
blood, and in both these ways they may tend to restrain hae- 
morrhage. 

Of those which cause both contraction of the vessels and co- 
agulation of the blood, the most powerful are acetate of lead, 
alum, sulphate of copper, chloride of zinc, nitric and sulphuric 
acids. Other styptics, as nitrate of silver, sulphate of zinc, sul- 
phate of iron, and infusion of nutgalls, are certainly astringent, 
and are generally supposed to coagulate the blood; but Mr. 
Blake's experiments show that they have not this latter effect 
when injected into the veins of living animals, (see note to § 214.) 
It is, however, possible that, in a concentrated form, as where 
applied topically, they may coagulate the blood in the bleeding 
vessels. This seems to be the effect of nitrate of silver when 
applied to leech-bites. The actual cautery operates in a similar 
way. 

In some cases of haemorrhage, the styptic remedies may be 
applied directly to the bleeding part, as in epistaxis, haematcme- 
sis, haemorrhoids, and uterine haemorrhage. In epistaxis, solu- 
tions of alum, acetate of lead, and sulphate of zinc, are sometimes 
injected into the nostrils, or applied by sponge or lint. In haema- 
temesis, sugar of lead, alum, gallic acid, oil of turpentine in small 
doses, and the mineral acids, given by the mouth, operate directly 
on the bleeding part. In excessive haemorrhoidal flux, enemata, 
containing some of these remedies, are immediately beneficial. 

371. In many instances, the bleeding part is beyond the reach 
of the direct application of styptic remedies; yet some of these 
administered internally show considerable power in restraining 
the haemorrhage. Thus haemoptysis is assuredly sometimes 
checked by frequently repeated doses of sugar of lead, (which 
should be combined with a little opium or conium, to prevent its 
griping the bowels;) and, according to some practitioners, by 
ipecacuanha, gallic acid, alum and other astringents. Haematuria 
of the passive kind is diminished by small doses of oil of turpen- 
tine; passive uterine haemorrhage by ergot of rye, and tincture 
of the sesquichloride of iron. Opium given internally has been 
found effectual in some cases of uterine haemorrhage. It is diffi- 
cult to explain how it operates; but it is probably through that 
property by winch it diminishes many secretions. 



RESULTS OF HYPEREMIA FLUX AND DROPSY. 1S3 

372. Ill some kinds of haemorrhage, especially those of the 
intestinal canal, the most effectual remedies are those which in- 
crease the proper secretions of this canal and of its allied glands; 
such as mercurial and saline purgatives, in combination with 
others of a styptic kind, such as sulphuric and nitric acids, alum, 
and sulphate of zinc. This mode of treatment is often sufficient 
in slight haemorrhages, or dispositions to haemorrhage from the 
lungs and uterus, and in purpura haemorrhagica; and there can 
be little doubt that it operates on the condition of the blood, as 
well as by its evacuant and styptic effects. 

II. FLTJX AND DROPSY. 

373. Another result of various kinds of hyperaemia is an effu- 
sion of the watery part of the blood with more or less animal 
and saline matter in solution. This result occurring in secreting 
organs or open surfaces, constitutes fluxes; in closed sacs or 
cellular texture, it constitutes dropsies. There is so much that 
is common in the pathology of fluxes and dropsies, that we shall 
avoid repetition by exemplifying them together in the first place; 
and we can afterwards notice their distinguishing peculiarities. 

374. General plethora sometimes ends in flux or dropsy; but 
such a result most commonly ensues where the blood-vessels are 
temporarily distended with an undue proportion of watery con- 
tents. Thus, if much water be slowly injected into the veins of 
an animal, the circulation and breathing become embarrassed; 
and after a time dropsical effusions take place into the abdomen, 
the chest, and the cellular texture; or a flux (excessive flow) 
takes place from the kidneys, intestines, or skin; or all these re- 
sults may occur; and the blood-vessels are relieved of their dis- 
tension. The same events have sometimes arisen from excessive 
drinking of any liquid, but chiefly where the kidneys and the 
skin, the natural emunctories for superfluous fluid in the body, 
have failed in their office. The drinking largely of a cold liquid 
when the body is perspiring and fatigued, checks the cutaneous 
and renal secretion; the blood-vessels become filled to tension, 
and may relieve themselves in dropsical effusions or diarrhoea. 
External cold sometimes operates in a similar way; it arrests 
perspiration, and causes internal congestions, (§ 292;) and if, from 
previous over-excitement or other defect, the kidneys are,unequal 
to perform what the skin fails to do, general fulness is the result, 
whirl i tends to issue in some dropsy or flux. The sudden sup- 
pression of a cutaneous eruption, or of the discharge from an 
old olcer, has sometimes been followed by anasarca, diarrhoea, 
or bronchia] dux, (humid asthma.) The colliquative sweats of 
advanced phthisis are of the natureofa flux, by which the blood- 



1S4 PROXIMATE ELEMENTS OF DISEASE. 

vessels, in their obstructed and reduced state, relieve themselves 
of superfluous liquid. These sweats may generally be stopped 
by a judicious restriction in liquid food. 

375. If we seek instances of local congestion terminating in 
flux and dropsical effusion, we easily find them in almost every 
variety of congestion that has been enumerated, (§ 288, et seq.) In 
fact, these are the most common causes of partial dropsies. 

The adequacy of venous obstruction to produce dropsy is well 
illustrated by some experiments of Lower. He tied the jugular 
veins of a dog, expecting the animal to die of apoplexy; instead 
of this, the face and head of the animal became much swelled 
with oedema. He then tied the ascending cava; ascites and ana- 
sarca of the lower extremities were the result. Disease affords 
numerous examples of dropsy and flux from venous obstruction. 
Aneurism of the arch of the aorta, or other tumours, by pressing 
on the venas innominatsc, or descending cava, sometimes cause 
oedema of the face and upper extremities. In a case (under my 
care) of malignant tumour involving the roots of the lungs, there 
were hydrothorax and flux into the bronchial tubes, (bronchor- 
rhoea.) In advanced pregnancy and ovarian dropsy, the legs 
swell from pressure of the tumour on the iliac veins. Many in- 
stances are recorded in which obliteration of a large vein was 
followed by dropsy of the part from which the vein proceeded. 
The ascending cava has been found obliterated in persons who 
had long been affected with ascites and anasarca of the lower 
extremities. In the University College collection, there is a 
drawing of such a case, in which a supplementary circulation 
had been established by an enormous enlargement of the super- 
ficial veins of the abdomen. Dr. Watson relates an instance of 
the same kind.* M. Tonnele has made some observations which 
favour the opinion that chronic hydrocephalus is caused by a par- 
tial obliteration of the venous sinuses of the head, (§ 267.) 

But the most common causes of venous obstruction are certain 
visceral diseases, and these commonly produce either dropsy or 
flux. Thus the contractile - disease of the liver, cirrhosis, is the 
most frequent cause of simple ascites; and in connection with 
various functional and structural diseases of the liver, diarrhoea 
and gastrorrhoea (watery eructations) are apt to occur. Struc- 
tural disease of the heart, especially if seriously affecting the 
orifices or valves, commonly causes hydrothorax, bronchial flux, 
(humid asthma,) and sometimes general dropsy. Pulmonary 
congestion from causes impeding the respiration, (§ 298,) such 
as spasmodic asthma, emphysema, laryngitis, hanging, and coma, 
sometimes results in a branchorrhcea or hydrothorax. In the 

* Library of Medicine, Art. " Dropsy," vol. v. 



FLUX AND DROPSY — EXAMPLES. 1S5 

experiments of Dr. J. Reid, a serous flux into the bronchial 
tubes ensued after the division of the par vagum, which, by im- 
pairing the respiratory action, induces pulmonary congestion.* 

376. As we found congestion to arise from weakness of the 
circulation and atony of the vessels, (§ 290,) so dropsical effu- 
sions and fluxes may proceed from the same causes. Thus 
oedema of the lower extremities is a common sign of extreme 
weakness; as after severe illness, and towards the fatal termina- 
tion of many chronic diseases. Colliquative diarrhoea and per- 
spiration (fluxes) sometimes occur under similar circumstances. 
The oedema and fluxes which arise from weakness will be more 
readily induced by postures which cause gravitative congestion 
in the affected parts. Thus continued standing causes swelling 
of the legs, and leucorrhoea, in persons liable to these results of 
congestion. 

377. Fluxes and dropsical effusions sometimes occur after pre- 
vious excessive excitement of the vessels of a part. Hence 
oedema after erysipelas, and the infiltration of serum in cavities 
and textures after excessive excitement of the vessels of these 
parts, even when no inflammation has been induced. The gleets 
or fluxes which follow inflammations of the urethra, bronchi, ali- 
mentary canal, and vagina, seem to be connected with the same 
condition of the vessels that sometimes causes congestion, (§294.) 
Persons who indulge in spirituous liquors often suffer in the 
morning from waterbrash, for which they find a glass of spirits 
the best remedy: in this case, however, obstruction in the liver 
(§ 56, 371) may also co-operate. 

378. Fluxes sometimes arise from the intropulsive operation of 
cold, (§ 77, 292;) thus diarrhoea and catarrhal affections, too 
transient to be considered inflammatory, are frequently thus in- 
duced; and diuresis (flux of urine) is a more healthy example of 
this effect of cold. It is doubtful, whether this operation of cold 
will suffice to cause dropsy; but it may increase it where it ex- 
isted previously. 

379. The other variety of local hyperemia, determination of 
blood, (§ 321,) may produce fluxes and dropsies. The influence 
of various stimulants on secreting organs and surfaces illustrates 
the production of fluxes in this way, (§ 324.) Thus snuff in the 
nose determines a flow of nasal mucus and of tears; spices in the 
mouth provoke a discharge from the salivary glands; irritating 
vapours inhaled cause a flux in the air-tubes; purgative medi- 
cines induce a flux from the intestines, &c. In these cases, the 
irritation is short of inflammation, which, although attended with 
determination of blood and effusion, comprises thither effects. 

• Edin. Med. and Surg. Jour., vols. 49, 51. 
16* 



186 PROXIMATE ELEMENTS OE DISEASE. 

The fluid thus secreted in these several cases of flux from deter- 
mination of blood, differs from the products of inflammation: it 
commonly consists of the natural secretion of the part diluted 
with an unusual proportion of water and saline matter from the 
blood, and the excess of saline matter sometimes gives the secre- 
tion an irritating quality, as in the fluid of coryza, bronchorrhoea, 
and watery diarrhoea. 

Other examples of flux may be referred to determination of 
blood without special irritations; as the leucorrhcea which pre- 
cedes and follows the menstrual period, the bronchorrhoea or gas- 
trorrhoea in some cases excited by increased action of the heart, 
and the sweat succeeding to flushes of blood to the head or other 
parts. 

380. Dropsy is less frequently a result of simple determination 
of blood; because, independently of inflammation, there are few 
causes for such determination to closed sacs. But probably the 
dropsy accompanying tubercles in the peritoneum and mem- 
branes of the brain may in some degree be induced by the me- 
chanical irritation of the tubercles causing a flow of blood to the 
membranes. The sudden mode of attack which tuberculous 
hydrocephalus sometimes exhibits seems to countenance the 
same opinion. These cases exhibit the phenomena of determi- 
nation of blood to the head, described before, (§ 323,) but here 
this proceeds to effusion of serum, with its more permanent 
symptoms. The kinds of dropsy called inflammatory may be 
included under this head; but we shall shortly see that the deter- 
mination of blood, or excitement of the circulation, sometimes 
present in such cases, is consequent on an altered condition of 
the blood itself. 

3S1. As flux and dropsy commonly arise from similar condi- 
tions of the vascular system, so they are sometimes found to suc- 
ceed to one another. Thus Andral mentions a case in which 
hydro thorax was removed on the occurrence of a profuse flux from 
the air passages. Examples are not uncommon of the subsidence 
of ascites on the occurrence of diarrhoea, or of the supervention 
of ascites when a diarrhoea of long duration has been suddenly 
checked. Dr. Watson quotes from Dr. Farre's lecture an in- 
stance in which hydrocele was removed by violent purging. It 
is a more familiar fact that the occurrence of dropsy is attended 
by a marked diminution of the urinary secretion, and that a free 
flow of this often reduces the dropsy. On a knowledge of the 
preceding facts may be founded the most effectual treatment of 
dropsy. 

382. Enough has been said to show that flux and dropsy, as 
well as haemorrhage, are occasional results of hyperaemia in its 
different varieties. But what are the circumstances which deter- 



FLUX AND DROPSY — PECULIAR CAUSES. 187 

mine these results? In the case of haemorrhage, we found the 
additional or determining cause to be in the vessels or in the 
blood, (§350.) So certain conditions of these favour the occur- 
rence of flux and dropsy. An extreme amount of vascular dis- 
tension will pretty certainly result either in rupture and haemor- 
rhage, or in the exudation of the watery parts of the blood, 
(§ 305, 340,) and the long continuance of congestion or plethora, 
by making the exhalation predominate over absorption, rarely 
fails to lead to similar consequences. But in some cases both 
dropsical effusions and fluxes take place with a facility dispropor- 
tioned to the amount of hyperaemia or to its duration: and in 
these cases the cause may be traced to a generally lax, flabby 
state of the tonic and contractile fibre, (§ 123,) or to a poor wa- 
tery state of the blood, (§ 222,) or to both these conditions to- 
gether. Persons liable to these affections are usually of pale 
complexion and phlegmatic temperament, (§ 40.) 

The influence which relaxation of the solids has in producing 
profluvial and hydropic affections is exhibited in the occurrence 
of these results, in parts after over-excitement, (§ 294,) where 
there is no indication of general disease of the blood. But in 
cases also in which the blood is diseased, there is usually a re- 
laxed state of the vascular fibre; and it is not easy to distinguish 
the separate influence of these causes. Thus the liability to 
dropsy and fluxes, after long fevers, defective nourishment, (§63, 
196',) or confinement in impure air, must be attributed to the joint 
operation of both classes of causes. 

383. The conditions of the blood tending to watery effusions 
require further consideration. A poor or watery state of the 
blood, above noticed, is the most obvious of these; and that this 
is alone sufficient is plain, from the fact that injecting water in 
quantities into the veins of an animal, will cause watery effusions 
or discharges, whilst the injection of blood or serum does not 
produce this effect. Persons who have lost much blood are liable 
to become dropsical from the same cause; the bulk of the lost 
blood is replaced by watery serum absorbed from various 
sources; and thus the blood is in a diluted state, (§264.) The mode 
in which a watery blood tends to produce dropsy and flux, is not 
merely by the greater prone ness of thin fluids to transude through 
the walls of the vessels, but also by the failure and irregular dis- 
tribution of the force of the circulation. It has been already 
explained, under the head of anaemia, (§ 262,) that a scantiness 
of blood embarrasses the circulation. The structure of the heart, 
its valves and vessels, is adapted to certain degrees of spissitude 
and quantity of the blood; and when these vary much from the 
natural Btandard, when the Wood instead of being of an unctu- 
ous fluidity, is watery and squashy, the hydraulic and moving 



1S8 PROXIMATE ELEMENTS OP DISEASE. 

apparatus of the heart and vessels is less capable of effecting its 
propulsion; and this condition of the blood may thus not only 
facilitate watery effusions, but promote the congestions and other 
imperfections in the circulation with which flux and dropsy are 
commonly connected. 

3S4. Several of the circumstances which induce the thin state 
of the blood have been already stated, (§ 222, 249, 382,) and in 
its relations to dropsy, we would more particularly advert to im- 
perfect excretion by the kidneys, liver, and skin, as the most 
common cause. In various forms of hyperaemia, which lead to 
dropsy and flux, (plethora, congestion, and determination of 
blood,) it will be generally observed that these results ensue in 
proportion as the excreting organs fail, and that the removal of 
these results is to be effected chiefly by means which restore or 
compensate the defective excretion. In many instances, exposure 
to cold has been followed by dropsy; and at first sight this might 
seem to operate merely by checking perspiration, and thus re- 
taining in the vessels water that should be eliminated, and which 
is then effused within the body. But checked perspiration alone 
will not cause dropsy: there must be a failure also in the action 
of the kidneys before this result will ensue. If these act pro- 
perly, checked perspiration may disorder the circulation, and 
cause congestions, inflammations, and even fluxes; but I have 
never. met with a case of dropsy arising from exposure to cold, 
in which the mine was not diseased, and, in the great majority of 
instances, albuminous. 

The circumstances under which exposure to cold induces 
dropsy, are such also as impair the action of the kidneys. A 
man in a lit of intoxication lies for several horns of the night on 
the cold damp grass; he arises much chilled, has shivering suc- 
ceeded by fever, and general dropsy ensues: the urine is very 
scanty, and on examination is found to be highly albuminous. 
The vital properties of the kidneys had been exhausted by the 
excitement of the stimulant beverage, so that when cold checks 
the perspiration and throws the blood on internal organs, the kid- 
neys cannot perform their usual vicarious action; their vessels 
become distended with blood, and mechanically exude serum 
instead of separating the proper constituents of urine, (§ 309;) 
these and the superfluous water accumulate in the blood, and, by 
their quantity and irritating quality cause effusions of serum con- 
taining urea in different parts of the body, as well as various 
other functional disorders before noticed, (§ 170.) 

Another instance of a similar kind of general dropsy is that 
supervening after scarlatina. This has been ascribed by some to 
a sub-inflammation of the cellular texture, originating in the 
eruption; by others to the diseased state of the skin, left by the 



FLUX AND DROPSY CAUSES. 1S9 

eruption, suppressing the perspiration. But if either of these 
were the true cause, the dropsy ought to occur most in the cases 
in which the eruption is most abundant, which is by no means 
the fact; nay, I have treated several patients in whom anasarca 
followed a scarlatina fever, with sore throat, without any rash at 
all. But in all these cases the urine has been albuminous, which 
again shows that the diseased action of the kidney is the most 
essential lesion connected with general dropsy. How scarlatina 
impairs the function of the kidney is a question too extensive to 
be discussed here; but I will simply state my belief that it does 
so by causing in these glands a highly congested state, which in- 
jures their secreting power, (§ 304,) as a parallel effect is observed 
with regard to the liver in bilious and intermittent fevers. A 
female under my care for albuminuria, which was' almost cured, 
became affected with scarlet fever: the urine, which had been 
merely hazy by heat and nitric acid, now become highly coagu- 
lable, and continued so until the fever declined, when it again 
gradually decreased. 

The general dropsical state occurring towards the fatal termi- 
nation of structural disease of the heart, I have in several cases 
found to be connected with albuminaria and slight jaundice, and 
I have been long in the habit of pointing out these as the most 
surely fatal complications to which heart diseases naturally tend; 
their connection has been before noticed, (§ 305, 309.) 

385. The pathological effect of secretion of serous and scanty 
urine (oliguria) have been already described, (§ 249, 170,) but 
AY r e must advert to the mode in which it induces dropsy and flux. 
Where resulting from a suddenly operating cause, such as expo- 
sure to cold, or scarlatina, a febrile state is generally present, 
with a frequent and hard or sharp pulse, heat of skin, thirst, &c. 
These symptoms occurring in conned ion with anasarca have led 
to the use of the terms inflammatory, febrile, acute or active 
dropsy; and so far as these terms only imply an excited state of 
the vascular system, they cannot be objected to. But some have 
employed them to explain the cause of the dropsy, as if this pro- 
ceeded merely from the excitement or inflammatory condition. 
That such a condition is present, is obvious not only from the 
febrile symptoms just mentioned, but also from the buffy state 
of the blood drawn, and from the dropsical ell'usious and fluxes 
being in many cases combined with the symptoms and products 
of inflammation. Thus the anasarca is often attended with great 
tenderness, and sometimes with an erysipelatous redness: swell- 
ings of the joints frequently have the character of rheumatic 
inflammation; effusion in the abdomen and pleura is often ac- 
companied by pain <>r tenderness, and after death slight deposits 
of lymph are found in addition to the serum; catarrhal llux from 



190 PROXIMATE ELEMENTS OF DISEASE. 

the bronchi, and diarrhoea, are associated with symptoms of more 
irritation (spasm, constriction, cough, vomiting, pain, and sore- 
ness) than occur with simple fluxes. 

Now this inflammatory character may be readily explained by 
referring it to the irritating quality of the excrementitious matter 
which the failing function of the kidneys leaves in the blood. 
Under such circumstances, urea has been found in the blood and 
in various effusions, and may be fairly regarded as the materies 
morbi which irritates various parts, and from which the system, 
seeking to relieve itself, (§ 17,) excitement and sundry effusions 
or discharges ensue. In two points this condition resembles acute 
rheumatism, (§ 351,) — 1. in the number of parts which may be 
simultaneously or successively affected; 2. in the want of any 
constancy in the seat of the affections. Both these points indicate 
that the cause is not essentially in any part, but in the blood. 
Another circumstance which approximates these affections to gout 
and rheumatism, is the nature of the excrementitious matter 
which accumulates in the blood. In the latter affections there is 
good evidence that lithic and lactic acids are the chief ingredients 
of this matter; but I have so commonly found an excess of urea 
in the urine of patients recovering from rheumatism, and the 
chief remedies for gout and rheumatism so distinctly increase the 
elimination of this principle, (§ 257,) that we can scarcely doubt 
that in these affections urea also is either produced in excess, or 
insufficiently excreted. The proximity in composition between 
lithic acid and urea, and the probable conversion of the former 
into the latter, (Liebig,) should not be forgotten. Both gout and 
rheumatism, like oliguria, sometimes produce fluxes or catarrhal 
affections. Lastly, the connection between these affections is ap- 
parent from the fact, that rheumatism is frequently complicated 
with albuminuria, (as after scarlatina;) and granular degeneration 
of the kidneys (Bright's disease) is apt to supervene in the most 
aggravated forms of rheumatism. 

386. But besides the retention of excrementitious matter in the 
blood, there is a loss of albumen from' this fluid. That this loss, 
by thinning the blood, facilitates dropsical and profluvial effu- 
sions, is most probable in all instances; but this seems to be the 
especial cause of these results in the more chronic cases, and in 
the most anaemic subjects, for in these (as it has been already 
stated, § 264,) the blood is thinner and more watery than in any 
other disease. Thus in advanced stages of granular degeneration 
of the kidneys, and sooner in anaemic subjects, almost every con- 
gestion or determination of blood ends in watery effusion. As 
the powers of the circulation fail, the effusion is connected chiefly 
with gravitative congestion, (§291,) and occurs most in the lower 
extremities; in this respect differing from the dropsy of acute 



FLUX AND DROPSY DISTINCTIONS. 191 

albuminuria, in which the swelling also affects the face, trunk, and 
upper extremities. This form of dropsy is well entitled to . the 
appellation — asthenic or passive, both from being connected with 
congestion and weakness of the circulation, and from the poor 
condition of the blood, and depressed or cachectic state of the 
functions dependent upon it, (§ 262, 1S5.) 

387. From the preceding statements,, it maybe inferred that 
acute dropsy arises chiefly from the retention in the blood of ex- 
crementitious matter and water, which the kidneys fail to elimi- 
nate; and that the more chronic or asthenic kinds, although often 
originating in the same way, are rather dependent on a poor or 
watery state of the blood, especially deficient in albumen, (§ 222.) 
This deficiency in many cases arises both from the continued 
drain by the loss of serum in the urine, and from the imperfect 
assimilation and nutrition connected with this state. But we 
have good evidence that the more chronic and asthenic forms of 
dropsy may arise from the same state of the blood, independently 
of disease of the kidneys. Thus Andral and Delafond found 
dropsy in anasmic sheep in connection with cysticerci of the liver, 
but only in those cases in which the albumen of the blood was 
below the natural standard. So too in the human subject; the 
dropsy induced by very scanty or poor food, or close confinement 
in unhealthy places, or malarious districts, and that supervening 
in extreme states of debility or cachexia, are probably dependent, 
not merely on weak or obstructed circulation, but also on an im- 
poverished condition of the blood itself. For the same reason, 
the various structural diseases which cause congestions, espe- 
cially those of the heart and liver, often do not induce dropsy 
until the quality of the blood is impaired, either by imperfect ex- 
cretion, or by inadequate nutrition. 

388. We have thus traced flux and dropsy in common, to ele- 
ments previously considered, hyperemia in some of its forms, 
together with a diseased condition of the blood itself, (§ 222,) 
dependent on defective secretion, (§ 249, 250,) or defective nu- 
trition or assimilation, (§ 268.) The latter element, although not 
essential to the production of fluxes or local dropsies, is the chief 
cause of general dropsy, and constitutes the dropsical diathesis. 
If we endeavour further to distinguish between the pathological 
causes of flux and dropsy, we find from observation that flux 
more commonly results from determination of blood or conges- 
tion, with a lax state of the solids, (§ 123, 382,) whilst dropsy is 
rather associated with the altered condition of the blood just no- 
ticed. 

389. The distinction just made between the causes of flux and 
dropsy implies that flux is generally a more partial disease than 
diopsy, many circumstances relaxing the vessels of a part with- 



192 PROXIMATE ELEMENTS OF DISEASE. 

out affecting the condition of the blood in the whole system. 
This is especially apt to occur in secreting organs and surfaces, 
which are in fact the common seat of fluxes. We have before 
noticed excessive secretion as a primary element of disease,. 
(§ 162,) but the fluxes which we are now considering consist less 
in excess of the natural secretion (although this often occurs also) 
than in the addition of a watery, saline, and sometimes albumin- 
ous fluid derived from the blood, a serosity in fact, (§ 305, 375.) 
The fluids discharged in chronic coryza, bronchorrhoca, gastror- 
rhoea, and watery diarrhoea, are the natural mucus of the respect- 
ive surfaces, much diluted with a thin serum, the saline matter of 
which often gives the secretion an irritating property. Some- 
times this serous fluid is substituted for the proper secretion, as 
in the coagulable urine of. the early stages of granular kidney, 
and the watery urine of its more advanced stages. 

The circumstances which commonly induce flux in secreting 
surfaces have been already noticed, (§ 37.6, el seq.,) but after a 
liux has continued for some time, it is apt to become habitual, 
apparently through permanent relaxation of these affected ves- 
sels. These become so weak that any circumstance disordering 
the circulation may bring on an attack of tbe flux. In fact, the 
flux becomes :ai outlet for superfluous fluid in the blood-vessels, 
and discharges that which ought to be evacuated through the 
kidneys,' skin, or bowels. 

GENERAL TREATMENT OF FLUX AND DROPSY. 

390. As there is much that is common to fluxes and dropsies, 
we may abridge our notice of the remedial measures to be op- 
posed to them, by first giving the treatment applicable to- both, 
and afterwards specifying that indicated for each class of results. 

In so far as "fluxes and dropsies depend on plethora, sthenic or 
asthenic, congestion in all its varieties, or determination of blood, 
the remedies for these several morbid elements (§ 283, el seq., 313, 
el seq., 342, el. seq.) must form part of the treatment. So, also, 
according to the prevalence of these constituent conditions, fluxes 
or dropsies may be more or less sthenic or active, or asthenic or 
passive, and more or less constitutional or local; and the treat- 
ment must be varied correspondingly. And according to whe- 
ther these conditions are tractable or not, fluxes and dropsies 
resulting from them may be more or less difficult to remove, and 
exhibit many varieties as to "duration and disposition to return. 
Thus fluxes and dropsies which arise from congestions caused by 
structural disease of the heart or liver, 'or by tumours compress- 
ing veins, (§ 375,) although often removed, are liable to return; 
but those arising from cold, (§ 378.,) weakness, (§ 376,) previous 



FLUX AND DROPSY TREATMENT. 193 

excitement, (§ 377,) or functional disorder, may, in many cases, 
be cured permanently. 

391. We have repeatedly stated the circumstances under which 
vascular congestion or fulness in itself suffices to induce dropsy 
and flux, (§ 306, 383;) and under these circumstances, the reme- 
dies for congestion and plethora are the first to be used. Thus 
in dropsy or fluxes suddenly induced by structural disease of the 
heart and liver, often brought on by cold, over-exertion, or ex- 
citement, whilst the condition of the blood has not materially 
suffered, depletion, general or local, is advantageously premised 
before the use of other measures. Then follow remedies which, 
by increasing the secretions, reduce the remaining congestion and 
the effusions resulting from them: combinations of mercury or 
antimony with squill and digitalis are peculiarly serviceable in 
accomplishing this object. Various other means contribute to the 
same end, chiefly those which act as evacuants and derivatives. 
This treatment approaches to the antiphlogistic, as we have 
already found the nature and products of congestion of high 
tension, and of sthenic plethora, approximate those of inflamma- 
tion, (§ 307.) But in the more peculiar causes of flux and dropsy 
— those that induce these results with slighter amounts of con- 
gestion or disordered circulation, (§ 382) — those which constitute 
the dropsical and profluvial diathesis, (§ 388,) — we find conditions 
generally betokening weakness, and requiring a tonic or more 
supporting plan of treatment; a relaxed state of the solids, and 
a watery condition of the blood. But even in the treatment of 
these cases, to derive from the weak or congested parts, and to 
increase defective excretions, are objects generally to be attempt- 
ed. Further details will be better described under separate heads 
of flux and dropsy. 

TREATMENT OP FLUXES. 

392. In all cases of flux, it is proper to derive from the affected 
part, and to promote the natural excretions in other directions, 
by some or other of the following means: warm bathing, warm 
clothing, exercise, friction, and stimulant applications to the sur- 
face, diaphoretic, diuretic, and aperient medicines. It is also 
necessary to avoid circumstances which promote congestion or 
determination of blood in the affected part, such as dependent 
position, exposure to heat, cold to other parts, too fluid a diet, &c. 
In addition to these measures, it maybe requisite to use others 
to counteract or remove the irritations or obstructions which the 
flux causes in the part which it affects. Thus demulcent and nar- 
cotic remedies are sometimes useful in catarrh and diarrhoea, to 
17 



194 PROXIMATE ELEMENTS OP DISEASE. 

soothe irritation, caused by the secreted fluid; at other times, ex- 
pectorants and purgatives, to promote its expulsion. 

393. The further treatment of fluxes will be guided by the 
state of the vascular function, whether sthenic or asthenic. As 
in case of haemorrhage, so with flux, it is sometimes attended by 
a hard, frequent pulse, heat of skin, and other signs of fever or 
of sthenic plethora: here evacuants, antimonials, sedatives, and 
even blood-letting, may be required. In fact, the disease bor- 
ders on inflammation, and needs a similar treatment. Some 
cases of flux, of a sthenic character, arise from gouty or rheu- 
matic matter in the blood: here colchicum and alkalies are the 
proper remedies, as they promote the removal of this matter by 
the kidneys. Others we have found to be connected with albu- 
minuria, (§ 380,) and are to be treated as dropsy from that cause. 
In all these examples of sthenic or active flux, it is neither useful 
nor safe to attempt hastily to check the discharge by astringent 
remedies, lest the determination of blood attending it end in a 
worse result, haemorrhage or inflammation. 

394. The majority of fluxes are, however, asthenic, connected 
with a weak state of the vessels, local or general; and here 
other remedies are needful. Together with more or less of the 
general measures above described, (§ 392,) it is here safe and 
proper to endeavour to check the profuse exhalation, by astrin- 
gents, stimulants, and general tonics. Astringent remedies are 
most effectual by direct application; and their mode of action, by 
constricting the relaxed vessels, (§ 388,) is obvious. Thus ace- 
tate of lead, sulphate and acetate of zinc, sulphate of copper, 
nitrate of silver, alum, and some vegetable astringents, are effec- 
tual in leucorrhcea and diarrhoea. Some of these remedies seem 
also to act through the medium of the circulation. Thus sugar 
of lead, sulphate of zinc, and mineral acids, given internally, 
sometimes distinctly diminish bronchial flux and profuse per- 
spiration, as we have already found they sometimes arrest 
haemorrhage, (§ 367.) Some fluxes are remarkably checked by 
remedies whose operation seems to be rather stimulant than 
astringent. Thus spices, essential oils, and brandy, some- 
times cure pyrosis and diarrhoea; cantharides diminish leucor- 
rhoea; cubebs and copaiba, gonorrhoea; balsams of copaiba and 
Peru occasionally check bronchorrhoea. It is uncertain how 
these remedies operate; but it is probably by removing con- 
gestions by causing determination of blood, which excites con- 
traction, and a new condition of the capillaries of the part, 
(§ 317.) They are most successful in asthenic cases originating 
with inflammation. Another remedy occasionally useful in con- 
trolling fluxes is opium: its mode of operation is equally uncer- 
tain; but it is probably connected with its power to diminish 



FLUX AND DROPSY TREATMENT. 195 

natural secretions, (§ 166). Its efficacy is most obvious in diar- 
rhoea and diuresis; . and it is sometimes beneficially combined with 
metallic astringents in bronchial and gastric flux. 

The state of the system in persons subject to fluxes is gene- 
rally one of relaxation, and is therefore benefited by tonic medi- 
cines. Some of these have also an astringent property, which 
peculiarly adapts them for the treatment of asthenic fluxes. 
Thus the tincture of the sesquichloride of iron is useful in the 
treatment of leucorrhoea and humoral asthma, attended with 
much debility; infusion of cusparia in diarrhoea; and bark or 
quinine, with mineral acids, in various fluxes in very relaxed 
habits. 

For similar reasons, the diet should be as generous as the di- 
gestive organs will bear; sometimes including animal food twice 
a-day, and a moderate allowance of some sound fermented liquor. 
Excess in' liquid food should be particularly avoided, especially 
tea, and warm slops generally. Catarrhal colds, which are acute 
fluxes, I am in the constant habit of curing simply by total ab- 
stinence from liquids during two or three days; and although this 
extent of dry regimen is obviously inapplicable to chronic cases, 
yet moderation in the use of liquids, especially before or during 
exposure to cold, is an important part of the treatment in all cases. 
I have known several instances of chronic coryza and bronchor- 
rhoea kept up, if not brought on, by immoderate indulgence in tea 
and such liquids. These fluids cause a temporary plethora, which 
immediately finds vent through the lax vessels of the weak part, 
(§ 389.) The propriety of warm clothing, regular exercise, and 
a bracing, but not too cold an atmosphere, is obvious from the 
previous considerations. 

TREATMENT OP DROPSY. 

395. In addition to the means requisite to remove the variety 
of hypera)mia inducing the dropsy, (§ 391,) we have to remedy, 
as far as we can, those conditions of the blood which we have 
found (§ 384) specially to favour the occurrence of dropsy. Of 
the causes of these, a failure in the secreting power of the kidneys 
is the chief: its sign being an albuminous state of the urine, with 
a deficiency of the natural constituents of this excretion. The 
treatment must therefore have regard to the condition of the kid- 
neys, which is the chief cause of this failure in their action, and 
to the state of the blood and other parts, which is the result of 
th;ii failure. 

We have several times pointed out (§ 309) reasons for sup- 
posing a highly congested state of the kidneys to be the first 
cause of that failure in their function which induces albuminuria 



196 PROXIMATE ELEMENTS OF DISEASE. 

and its consequences. The means found most successful in re- 
moving dropsy arising from renal disease correspond well with 
this view. Thus in acute or inflammatory dropsy, occurring after 
scarlatina or exposure to cold, (§ 384,) blood-letting, especially by 
cupping to the loins, hydragogue purgatives, and diaphoretics, 
are advantageously used at first; and subsequently some kinds of 
diuretic medicines, particularly tincture of cantharides, digitalis, 
and colchicum, sometimes promote the natural action of the kid- 
neys. Such measures, if employed at an early period, before the 
disease in the kidneys has affected the structure, are often com- 
pletely successful. They fulfil, not only the indication of dimin- 
ishing the renal congestion, but that also of purifying the blood 
from excrementitious matter, and in reducing the sundry effu- 
sions, local irritations, and disturbances, which this matter excites 
in various parts, (§ 385.) They cure the dropsy by exciting an 
artificial flux, (§ 381.) 

Of the hydragogue purgatives used in the treatment of acute 
dropsy, I have found cream of tartar in large doses, (si v. to ^x. 
every morning or every alternate morning,) and extract of elate- 
rium, (^ gr.) the most effectual. Tartarized antimony, alone, or 
combined with opium, is the best diaphoretic, and it often relieves 
the catarrhal symptoms commonly present. Care must be taken 
not to cause vomiting, to which there is often a natural tendency. 
Dr. Osborne recommends the vapour-bath, and Dr. Watson the 
hot-air bath, as means of deriving to the surface and causing per- 
spiration. After cupping to the loins has been repeated as often 
as the strength of the patient may indicate, in obstinate cases I 
have seen some benefit from blisters or other counter-irritants to 
the loins. 

The dropsical effusions are often soon dispersed by the pre- 
ceding measures; but the proof of the permanent benefit of the 
treatment is to be looked for in the progressive decrease of albu- 
men, and the increase of urea, and lithic acid in the urine. It 
often happens that, after the full use of depletion, cathartics, and 
diaphoretics, the condition of the urine becomes stationary, and 
does not advance towards a healthy standard. Then the diu- 
retics before named are sometimes very effectual in augmenting 
the quantity of urine, without increasing the albumen in it; and 
where this is their first effect, their continuance will often pro- 
duce a gradual diminution of the albumen. The tincture of can- 
tharides is more powerful than the others in exciting the action 
of the kidneys; and where it increases the urine, the dose may 
be augmented from tr|X. to "Ixx. or gss. thrice a-day; but if the 
smaller dose do not act as a diuretic, it is not safe to proceed to 
the larger, nor in fact, to persist with the medicine; for if it irritates 
the kidneys without increasing their secretion, it is sine to do 



DROPSY TREATMENT. 197 

harm. We have noticed the same circumstance in the treatment 
of congestion by stimulants, (§ 317;) if they fail to remove the 
congestion, they aggravate the mischief. Digitalis and colchicum 
are safer diuretics, inasmuch as they are less irritating to the kid- 
neys; but they are also less powerful. 

Mercury might be expected to be useful in removing conges- 
tion or low inflammation in the kidney, and in restoring its se- 
cretion; but it so speedily and severely salivates in such cases, 
without any equivalent benefit, that it is not generally eligible. 
The promptitude with which the gums are affected with mer- 
cury may be ascribed partly to the facility with which inflam- 
mations may be excited in any part, (§ 385;) and, in some mea- 
sure, to the failing action of the emunctories of the system 
permitting the mercury to accumulate more speedily than usual, 
(§ 260.) But mercury is peculiarly efficacious in dropsy connected 
with diseased liver; and, in combination with squill, digitalis, and 
henbane, or conium, forms the most useful diuretic in all recent 
cases of dropsy dependent on congestion without disease of the 
kidneys. 

396. We have found (§ 386, 387) that the asthenic forms of 
dropsy, and those of the most chronic character, are commonly 
connected with a watery, non-albuminous state of the blood, and 
general weakness of the system. To obviate this condition so 
far as possible by nourishing diet, tonics, and means to increase 
the strength, becomes here a leading indication. In cases de- 
pending on malnutrition or mere debility, (§ 3S7,) this tonic and 
supporting treatment may be sufficient to effect a cure. In the 
commoner examples of dropsy, rendered asthenic by the long 
continuance of structural disease of the kidneys, liver, or other 
organs, the same strengthening and invigorating measures must 
be more or less combined with means to excite the failing excer- 
nent organs, or to produce some compensating discharge. Thus 
in dropsy from chronic albuminuria, or advanced degrees of 
granular degeneration of the kidney, the occasional exhibition 
of hydragogue purgatives and diaphoretics, and of the diuretics 
before mentioned, is useful at the same time that bitters with 
iodide of potassium, or mineral acids, are given to keep up the 
general strength and powers of nutrition. In the more anajmic 
cases, iron is often of advantage; but it sometimes proves inju- 
rious by impairing the little secreting power remaining in the 
kidneys, and by rendering the urine more albuminous. Where it 
has this effect, its use must be abandoned. The preparations of 
iron that I have found most serviceable in these cases arc the 
aniiiioiiio-citrate in combination with iodide of potassium, and the 
muiiated tincture. 

Asthenic dropsy arising from diseased liver is sometimes sig- 
17* 



198 PROXIMATE ELEMENTS OF DISEASE. 

nally relieved by mercurial and diuretic medicines, followed by 
or even conjoined with calumbo, bark, and other vegetable tonics. 
In two cases under my care, ascites, of great extent and long du- 
ration, connected with granular degeneration (cirrhosis) of the 
liver, was removed, and the patients for a time restored to appa- 
rent health, by a course of hydragogue doses of cream of tartar 
every morning, or every other morning, with bark and nourishing 
diet in the day. Hydragogue purgatives are more directly useful 
in removing ascites connected with diseased liver, inasmuch as 
they excite a discharge from the congested vessels themselves, and 
substitute abdominal flux for abdominal dropsy, (§ 381.) But 
they often fail to excite a watery discharge from the intestines, 
and instead cause much irritation, with tenesmus, and slimy or 
bloody stools: under these circumstances they must be discon- 
tinued; but after blistering the abdomen, or applying leeches to 
the region of the liver or to the anus, (§ 319,) the useful opera- 
tion of hydragogue purgatives may sometimes be again obtained. 
Similar means will often facilitate the operation of diuretics. Dr. 
O'Beirne has argued strongly in favour of blood-letting in dropsy, 
under the impression that by relieving the pressure from congested 
blood-vessels, it enables secreting organs to act. (Dublin Jonrn. 
of Med. Sc, Nov. 1842.) Like most other writers on dropsy, Dr. 
O'Beirne does not seem to me sufficiently to regard the mixed 
character of the disease. 

397. The tendency of dropsy connected with diseased heart, 
kidneys, or liver, to recur again and again, and become chronic, 
renders it needful to vary as much as possible the remedies em- 
ployed, as well as to use means to support the strength. It is an 
important point in the treatment of such cases not to exhaust the 
powers of any secreting organ by too long acting on it, and not 
to expend the efficacy of any one remedy by too long continuing 
its use. By employing sometimes diuretics, sometimes purgatives, 
sometimes diaphoretics, and by aiding each of these, by local de- 
pletion or derivants, or by stimulants and tonics, according to the 
temporary prevalence of vascular fulness and excitement, or the 
converse, much may often be effected to prolong life. It is in the 
application of these rules to the treatment of prolonged cases, 
that the skill and resources of the rational practitioner are most 
tried, and his superiority over the routinist is best proved. It is 
under these circumstances, too, advantageous to have at com- 
mand a great variety of medicines, particularly diuretics, and to 
alternate them or vary them in order to increase or maintain 
their effect. Those that I have found most effectual are — com- 
binations of mercury, squill, digitalis, and conium, (not in acute 
albuminuria;) combinations of decoction of broom, or pyrola um- 
bellata, with nitrate and acetate of potass; the juice or extract of 



DROPSY TREATMENT. 199 

taraxacum, with the same salts or bitartrate of potass, or with 
nitric acid, (particularly in hepatic disease;) infusion or tincture 
of digitalis, with iodide of potassium, and bitartrate of potass, 
(in dropsy after scarlatina;) the same, together with increasing 
doses of tincture of cantharides, (in asthenic cases of albuminuria, 
after cupping to the loins and hydragogue purgatives;) ammonio- 
tartrate and ammonio-citrate of iron in Seltzer water, (in asthenic 
dropsy;) gin in cream of tartar beverage, (imperial;) compound 
spirit of juniper, spirit of nitric aether, with various others, (in 
cases of debility.) The latter stimulant diuretics have disap- 
pointed me more than any of the rest. 

398. When dropsical swellings have reached a certain amount 
of tension, diuretic and other remedies produce little or no effect 
on them. The veins and lymphatics, whose office it is to remove 
these swellings, are too much compressed to be capable of ab- 
sorbing. In the case of ascites, this pressure impedes the circu- 
lation through the kidneys and intestines, and their secretions 
are proportionally reduced, (§ 159.) Extensive hydrothorax, and 
even ascites, in a similar way embarrass the functions of the lungs 
and heart. Anasarca, in its extreme degrees, sometimes impedes 
the circulation in the vessels of the lower extremities, so far, as 
not only to prevent absorption, but even to cause the death of the 
parts: hence gangrene of the legs is a common termination of 
incurable dropsy. The gangrene is commonly preceded by an 
erysipelatous kind of inflammation, which often seems to origi- 
nate in some accidental scratch, or from the irritation of mechani- 
cal tension, or of the quality of the effused fluid. 

Now, in all these cases, the great expedient is to give exit to 
a portion of the fluid, by tapping or puncturing the parts which 
contain it. Thus the abdomen is tapped for ascites; the chest 
for hydrothorax; the scrotum for hydrocele; the brain for hydro- 
eephalus; ovarian and other cysts, when they attain a large size; 
and the legs are acupunctured for anasarca. The relief afforded 
by these means is sometimes very remarkable, even when much 
fluid is left unremoved. In fact, the great utility of these opera- 
tions seems to consist in the removal of an amount of pressure 
and distension that was seriously impeding the functions of the 
several parts. Accordingly we find, after these operations, not 
only a great mitigation of suffering, but a restoration of the func- 
tions of circulation, secretion, respiration, &c, which before were 
mechanically obstructed. After paracentesis, diuretic and other 
remedies regain their power, and contribute to reduce tin- re- 
maining illusion; and the secretions being free, the patient is 
ftble to bear nourishing food and strengthening remedies, which 
previously would have increased the excitement and oppression. 

The usual indications for the use of these surgical resources 



200 PROXIMATE ELEMENTS OF DISEASE. 

are, an amount of dropsical effusion which seriously injures the 
functions of circulation, secretion, or respiration, other remedies 
having failed to give relief. Under such circumstances the ope- 
rationshould not be delayed. In puncturing the legs for anasarca, 
it is proper to bear in mind the tendency to low inflammation 
and gangrene, and to avoid this, the skin and flesh should be in- 
jured as little as possible; numerous punctures should be made 
with a fine needle, but not too close together; and inasmuch as 
there is more tendency to this result where the circulation is 
weakest and most remote from the heart, it is better to avoid 
puncturing below the knees. 

Further details on these subjects properly belong to special 
pathology; and would be out of place here. 



SECTION VII. 
LOCAL HYPEREMIA. EXCESS OF BLOOD IN A PART. 

III. WITH MOTION PARTLY INCREASED, PARTLY DIMINISHED = 
INFLAMMATION. 

399. The morbid conditions connected with the quantity and 
motion of the blood hitherto described, have been pretty dis- 
tinctly defined; and we have been able to refer many phenomena 
of disease to them. We now come to one, the name of which is 
very familiar, and its frequency gives it so high an importance, 
that it has always attracted the first attention of pathologists; 
but although so commonly occurring, it is much more compli- 
cated in its nature than any of the morbid elements previously 
considered; in fact, it may be said almost to comprehend them 
all, besides being a still further deviation from the natural con- 
dition. 

The terms inflammation, phlegmasia, and phlogosis, have 
been used, from a very remote period, to give a figurative ex- 
pression of the heat, redness and burning and painful sensations 
which commonly exist in inflamed parts. The occurrence of in- 
flammation is so common, and its more prominent symptoms so 
familiar, that it has long been distinguished as a chief element of 
disease; in fact, it has, in a measure, engrossed the attention of 
pathologists so entirely, that other important elements have been 
almost overlooked; and this oversight has not only retarded the 
advancement of our knowledge with regard to these other ele- 
ments, but it has rendered the subject of inflammation itself less 
intelligible, by excluding the consideration of some of its com- 
ponent parts, and by keeping it in all its complexity and remote- 



INFLAMMATION — CAUSES. 201 

ness from the normal conditions of function and structure. We 
shall find, that an acquaintance with the ultimate and proximate 
elements of disease already considered in this work is essential 
to the proper understanding of the nature of inflammation; for 
these form the connecting link between the natural properties of 
living textures, and their extreme variation in the state of inflam- 
mation. The definition given above to distinguish inflammation 
from the other varieties of hypersemia — too much blood in a 
part, luith motion (of that blood) partly increased, partly dimi- 
nished — is easily recognized in the strong pulse of arteries lead- 
ing to an inflamed part, and in the stagnation of much blood in 
the part. 

400. The four signs which, from the time of Celsus, have been 
considered characteristic of inflammation, are redness, heat, pain, 
and sivelling. These signs are sometimes produced by conges- 
tion, (§ 303,) and by determination of blood, (§ 333, &c.;) but in 
a degree less marked, and for a time less continued, than in in- 
flammation; and although there are cases and forms of inflam- 
mation in which it is not possible to detect all these marks, they 
may still be said to constitute its most general character. In 
common with other varieties of local hypersemia, inflammation 
owes the sign of redness to the excess of blood in the part. As 
in determination of blood, the heat and pain are in part due to 
the increased motion of that blood. As with other forms of hy- 
periemia, the swelling arises partly from the over-distension of 
the blood-vessels, and partly from effusions from them; but in 
these effusions, inflammation differs from congestion and simple 
determination, departing still further than these from the natural 
quantity and quality of the effused matters. 

CAUSES OF INFLAMMATION, AND THEIR MODE OF OPERATION. 

401. Predisposition to inflammation has been already noticed 
tinder the head of predisposing causes of disease, (chap. i. sect. 2.) 
The circumstances which render the body liable to inflammation 
are those which especially affect the vascular system, whether 
these circumstances be the result of original conformation, as the 
sanguine temperament, (§ 38;) or whether they be the effect of 
previous disease, (§ 31,) of present disease, (§ 34,) or of external 
or internal causes in actual operation, (§ 20, et scq. 30.) Inas- 
much as various circumstances, external or internal, tend gene* 
rally or locally to impair the healthy (one and balance of the 
vascular system, (§ 123,) whilst muscular irritability (§ L12) and 
the quantity of the blood are not proportionally reduced, (§ 195,) 
so far they predispose to inflammation. Accordingly, we find 
persons prone to inflammation to be those whose circulation has 



202 PROXIMATE ELEMENTS OF DISEASE. 

been weakened or irregularly excited by previous disease, fatigue, 
confinement, impure air, or improper nourishment. But it will 
presently appear, that predisposition to inflammation differs ac- 
cording to the nature of the cause which excites inflammation; 
those most subject to inflammation from causes acting generally 
suffering more than others from causes which act only locally. 
Thus a depressed state of the whole vascular system favours the 
production of inflammation from causes acting generally, (such 
as cold;) whereas an excited state of the vascular system favours 
the development of inflammation from local irritation. 

402. The concluding part of the last paragraph prepares us to 
divide the exciting causes of inflammation into those which act 
locally on the part which inflames, and those which act more 
generally on other parts. The operation of the first class is 
direct; that of the second is indirect, therefore less certain, and 
more dependent on predisposition. 

The local exciting causes of inflammation comprehend irri- 
tants, mechanical, chemical, and vital. A grain of sand in the 
eye, a thorn in the true skin, and a bruise or wound in the flesh, 
are examples of mechanical irritants, or sources of irritation. 
Chemical irritants are those which operate on living matter by 
strong chemical affinity, tending to alter or decompose it;, such 
are heat, strong acids and alkalies, various corrosive salts, chlo- 
rine, iodine, &c: these act also on dead textures. Vital irritants 
are various agents whose irritating operation is not referable to 
any known chemical property, nor do they act on dead animal 
textures; of this kind are cantharides, mustard, capsicum, and 
essential oils. In this last class must be included various animal 
and vegetable irritant poisons; such as that of small-pox, and the 
venom of some noxious animals and plants, which act as local 
irritants, besides otherwise affecting the system. Various noxi- 
ous matters, sometimes generated in the living or recently dead 
body, are also capable of exciting inflammation when applied to 
an abraded surface, (§ 258.) Nay, the natural excretions of the 
body become most acrid irritants, when brought into contact with 
serous membranes; thus urine, faeces, and bile, effused in serous 
membranes, even in the smallest quantities, produce intense irri- 
tation and inflammation. 

Irritation and inflammation are sometimes caused by excre- 
mentitious matter retained in the blood, where the functions of 
the excernent organs are impaired, (§ 249, 251, 254.) Local in- 
flammations are also excited by certain poisons received into the 
system: thus arsenic, even when applied to a wound, causes in- 
flammation of the stomach and intestines; mercury excites in- 
flammation of the gums; the poisons of small-pox, scarlatina, 
and measles, inflame the skin, throat, and air-passages; that of 



INFLAMMATION CAUSES. 203 

syphilis the periosteum, throat, skin, iris, &c. In these cases, 
there can be little doubt that inflammation is excited by the 
actual presence of the peculiar irritating matter in the parts 
which inflame, conveyed there in the blood; and it is a leading 
character in the operation of these irritants "which are conveyed 
through the blood, that it affects several parts, or a considerable 
portion of the body at once; and frequently the two sides of the 
body in a similar manner. This is observed in the eruptions, of 
exanthematous and other skin diseases, in rheumatism, in syphi- 
litic nodes, &c. (§ 259.) 

403. The second class of causes exciting inflammation, those 
which operate indirectly, are of very common occurrence; and, 
although comprising fewer agents, they as frequently produce 
diseases as the more direct, causes of irritation. They comprise 
those which first produce congestion, which, on the occurrence of 
subsequent reaction, is converted into inflammation. The most 
common of these causes is cold, which, both by its local opera- 
tion, (§ 76,) and by its more general application, (§ 77,) may pro- 
duce congestions, (§296, 292,) which may pass into inflamma- 
tion. Malaria, and the influences which induce continued and 
eruptive fevers, as they produce congestions, (§ 293,) so they often 
lay the foundation of inflammations, which complicate the febrile 
affections excited by these causes. Inflammations sometimes arise 
out of the congestions caused by venous obstruction (§ 298) and 
gravitation. Thus pneumonia (with hepatization, and sometimes 
suppuration) frequently occurs in connection with disease of the 
heart, impeding the circulation; in adynamic fevers, and in the 
sinking which precedes death, (§290.) The congestions of the 
lungs, brain, and mucous membranes, that result from the appli- 
cation of various asphyxiating causes, (§ 298,) sometimes end in 
inflammations, which become a chief source of danger after the 
restoration of the respiration, (§ 235,243.) 

404. Suppression of natural or habitual discharges, especially 
the catamenia, the sudden drying up of ulcers, and repulsion of 
cutaneous eruptions, (§ 69,) are recognized as causes of inflam- 
mation, (§ 67.) So far as the inflammation excited by these causes 
is in, or contiguous to, the parts previously affected, local irritation 
may have a share in producing it; but where it is in distant parts, 
it probably results from a congestion or local determination of 
blood, which belongs to the second class of causes just specified. 
Very probably some of these causes of inflammation have a two- 
fold operation, that just specified, (producing a local fulness,) and 
thai of local irritation by morbid matters introduced into the cir- 
culating mass of blood. Thus the visceral inflammations arising 
on the sudden healing of a suppurating wound maybe promoted 
by local congestions resulting t'roni the cessation of the purulent 



204 PROXIMATE ELEMENTS OF DISEASE. 

discharge; but their circumscribed character, and the uniform 
event to which they tend, (suppuration,) seem to indicate a mor- 
bid matter in the circulating blood as the exciting cause of these 
inflammations. The same remark will apply to the inflamma- 
tions of the skin, fauces, and mucous membranes in scarlatina, 
measles, and small-pox; the follicular enteritis of typhus,* and 
the visceral complications of erysipelas, and other specific febrile 
affections. In all these, besides a general tendency to internal 
congestions, we seem to trace the irritating operation of the mor- 
bid poison on particular parts. 

405. We have noticed that sthenic haemorrhages (§ 363) and 
fluxes, (§ 393,) if too speedily checked without sufficient reduction 
of the circulation, are apt to pass into inflammation. So likewise 
determination of blood, if it be long continued, may issue in in- 
flammation, (§ 340.) The causes which excite determination of 
blood, when applied in a greater degree, or for a longer time, ex- 
cite inflammation. 

406. Before we proceed to examine into the nature of inflam- 
mation, we may properly inquire what is the mode of the opera- 
tion of its causes. It is generally assumed that the first movement 
of inflammation, as of all pathological processes, is in the nerves; 
but this is by no means proved. That some causes of inflamma- 
tion (irritants) operate first on the nerves, is probable from the 
following considerations. 1. Their action on the sensitive nerves 
is felt long before inflammation begins; thus the prick of a thorn 
in the skin, the smarting of caustic on a wound, the pain of the 
sting of an insect, are felt instantaneously; there is first nervous 
irritation; inflammation follows after. 2. The irritation is some- 
times transferred to other parts by sympathy, of which nerves 
are the channels: thus strong irritants in the nostrils may cause 
inflammation of the conjunctiva, a carious tooth or a diseased 
bone may irritate and inflame parts which are not contiguous to 
it. 3. An injury to a nerve is sometimes followed by inflam- 
mation in parts connected with this nerve. Thus paralyzed 
limbs are liable to become inflamed. Lallemand relates a case 
in which a ligature, involving the right brachial plexus, was fol- 

* I have observed an extraordinary development and inflammation of the iso- 
lated and grouped follicles of the intestines in the bodies of persons poisoned 
with arsenic. Their enlargement in epidemic cholera, and in the severe form 
of sporadic cholera and diarrhoea, caused by putrid effluvia, is well known. 
Are these glands excretory organs for the elimination of poisonous or noxious 
matters from the system? and in typhus fever, do they become inflamed and 
ulcerated by the continued operation of the poison in the exercise of this func- 
tion! The favourable influence of moderate diarrhoea in fever, the uncommon 
fcetor of the stools, the general relation between the duration of the fever and 
the affection of these follicles, the salutary operation of mild mercurial remedies, 
which promote their secretion, and oiher facts that might be adduced, give so 
much countenance to this question, as to make it worthy of attention. 



INFLAMMATION — OPERATION OF CAUSES. 205 

lowed by inflammation and suppuration in the opposite hemi- 
sphere of the brain. 

407. On the other hand, the following arguments may be ad- 
duced to show that the nerves are not essentially the seat of the 
first part of the process of inflammation. 1. Some of the causes 
of inflammation (the majority of those inducing internal inflam- 
mation) produce on the nerves or nervous system no known pri» 
mary effect, which resembles that of other causes of inflammation, 
(irritants:) thus inflammations excited by cold are often preceded 
by no marked nervous disturbance; whereas the strongest im- 
pressions of cold on this system are frequently not followed by 
inflammation, (§ 77.) 2. Inflammations often originate in con- 
gestions (§ 403) and in the sudden suppression of haemorrhages 
and other discharges, (§ 405,) without the occurrence of any 
symptoms referable to the nerves: hence inflammations thus 
arising may escape detection, and are called latent. 3. Persons 
in whom nervous properties are thus developed, (§ 126, 152, 
156,) are not those most susceptible of inflammation; and all va- 
rieties of nervous excitement are sometimes manifest in the high- 
est degree without any inflammation ensuing. Even where 
pain and other nervous symptoms are excessive, and are the re- 
sult of mechanical or chemical injuries, (such as crushed limbs, 
extensive burns, &c.,) inflammation sometimes does not follow; 
and this has led surgeons long to distinguish between irritation 
and inflammation. 4. Inflammation occurs in parts, the nerves 
of which are paralyzed or have been divided.* 

408. Seeing, then, that, inflammation is frequently excited 
without any obvious affection of the nerves, and is often not ex- 
cited when nervous irritation is most intense, it may fairly be in- 
ferred that an impression on the nerves is not an essential part 
of the first process of inflammation. That the nerves are con- 
cerned in many ulterior phenomena of inflammation, and in its 
extension, is fully admitted; and in the case of excitement of in- 
flammation by irritation, the primary operation of the exciting 
cause on the nerves has been already pointed out, (§ 406.) So 
far as is known, the blood-vessels are the essential seat of the 
whole process of inflammation, and although some of the exciting 
causes of inflammation (§ 402, irritants) act on the nerves as 
well, yet others (§ 403, as cold) operate chiefly and essentially 

* It is maintained by Dr. Copland and others, that in these cases, branches of 
the ganglionic system, distributed on the coats of the blood-vessels, are the first 
subjects of excitement. This is a mere hypothesis, which gives no aid in the ex- 
planation of the phenomena, because nothing is definitely known as to the pro- 
perties communicated by ganglionic nerves. Before the "influence of the 
ganglionic system" can be employed as an element in pathology, its existence 
must be proved, and its properties defined, in physiology: this has not been done. 
18 



206 PROXIMATE ELEMENTS OF DISEASE. 

only on the blood-vessels. Hence we find that the causes pre- 
disposing to inflammation (§ 401) are circumstances chiefly af- 
fecting the vascular system. A review of the exciting causes of 
inflammation (§ 402, 405) will show that in their mode of opera- 
tion on the blood-vessels they may be divided into two classes: 
1. those that cause determination of blood, (§ 322, 324;) and, 2. 
those that produce congestion, (§ 290, 299.) The former class 
comprehends all irritants, (§ 402;) the latter class includes cold 
and other agents, which directly produce congestion, (§ 403, 
405.) We have several times had occasion to mention that de- 
termination of blood, when exceeding certain limits, is apt to pas's 
into inflammation, (§ 340;) and that local congestions are liable 
to be converted into inflammation, (§ 292, 293, 306.) 

PHENOMENA AND NATURE OF INFLAMMATION. 

409. Having noticed the causes of inflammation, and traced 
their essential operation to be on the blood-vessels and their con- 
tents, we have next to inquire what is the character of their ope- 
ration on the vessels, and what phenomena it develops. 

That the blood-vessels are enlarged in an inflamed part is very 
obvious from the increased redness manifest to the naked eye. 
But in what respect does inflammation differ from congestion, in 
which also the vessels are enlarged? It differs not only in the ac- 
companying symptoms and in its products, but also in the ob- 
served condition of the vessels of the part. Thus besides greater 
pain and heat in an inflamed part, and earlier and more abundant 
effusions into or from it,the more florid hue of redness, the strong 
beating of the arteries leading to the part, and augmented quan- 
tity of blood flowing from its veins, clearly indicate that there is 
increased motion of the blood, instead of diminished motion, as 
in congestion, (§ 287.) 

Common observation of the pulse of arteries leading to inflamed 
parts would suffice to show that there is determination of blood 
to them; and some experiments performed by Dr. Alison and 
others have directly proved that these arteries are enlarged.* It 
was found that the arteries leading to an inflamed limb in a horse 
were considerably larger than those of the sound limb. John 
Hunter had arrived at the same conclusion from experiments on 
the ears of a rabbit. Now this enlargement has been before 
traced to diminished tonicity in the affected arteries, and this was 
found to be the chief instrument hi causing determination of 
blood, (§ 326, 327.) 

That the motion of the blood is increased through an inflamed 

* Trans, of British Association, 1835. 



INFLAMMATION — NATURE AND PHENOMENA. 207 

part, is distinctly proved by the. observation of Mr. Lawrence; 
venesection being performed at the same time, and in the same 
manner, in both arms of a patient with inflammation of the hand, 
a much greater quantity of blood flowed from the vein of the arm 
of the inflamed hand than from that of the other arm. 

410. It is certain, both from the preceding facts, and from direct 
observation under the microscope, that determination of blood is 
present in inflammation. The vessels in the vicinity of the in- 
flamed part are the channels of an increased flow, there being a 
flnx of blood to the whole inflamed part, and through some of its 
vessels. But if this were all, there would be no distinction be- 
tween determination of blood and inflammation; yet the greater 
redness and swelling and peculiar character of the effusion point 
out that inflammation is not mere determination. Microscopic 
research has established one great point of difference. The ob- 
servations of Thomson, Hastings, Kaltenbrunner, and Marshall 
Hall, have long clearly proved that there is no more or less 
obstruction to the passage of the blood in the vessels most in- 
flamed. Thus in the frog's web, when a part inflames from 
local irritation, the blood is seen to move more slowly in the part 
most irritated, and gradually accumulating in the vessels, renders 
them larger, redder, and more tortuous, until the motion ceases 
altogether in them, whilst neighbouring vessels are still the chan- 
nel of an increased current. A chief point then in which inflam- 
mation differs from determination of blood, is in the retarded or 
arrested flow of blood in some of the vessels. This answers to 
the definition which we have given of inflammation: too much 
blood in a part, loilh motion (of that blood) partly increased, 
partly diminished, (§ 399.) 

411. The question now naturally arises — What is the cause of 
the obstructed or retarded flow of blood through an inflamed 
part? This has ever been the chief difficulty in the pathology 
of inflammation; and it is especially to solve this that various 
hypotheses have been framed. Thus Cullen supposed a spasm 
of the extreme vessels to be the cause of obstruction, and there- 
fore the proximate cause (§ 13) of inflammation. Dr. Wilson 
Philip ascribes the same obstruction to a weakness of the capil- 
laries, which he presumes to incapacitate these vessels from 
transmitting the blood. John Hunter considered^ that there is 
something more active and vital in the enlargement of inflamed 
vessels, and he applied to it the term "active dilatation." The 
analogous expressions, "vital turgescence," "turgor vitalis," "in- 
flammatory erection," used by Kaltenbrunner and other German 
writers, imply a similar notion. 

The hypothesis of Cullen is quite ineonsistenl with direct ob- 
servation, the extreme vessels being seen under the microscope 



208 PROXIMATE ELEMENTS OF DISEASE. 

to be in a state of dilatation, not of spasm. This observation 
corresponds better with the idea of Dr. W. Philip, which was 
indeed founded upon it: but it has been objected by Dr. Marshall 
Hall and others, that the capillaries, by their contraction, do not 
aid in the circulation of the blood, and that their "debility" there- 
fore cannot be a sufficient cause for interrupted passage of blood 
through them. The words used by Hunter scarcely convey any 
explanatory meaning. They may be interpreted to assume the 
existence of a self-expansive power in the vessels, which power 
is supposed to act in inflammation as well as in natural formative 
or plastic processes in the animal body. But the existence of 
such a power is quite at variance with all that is known of ani- 
mal physics. A part may be expanded by elasticity, or by the 
injection or retention of fluid in it, but no direct vital expansile 
power has been ever proved to exist. The apparently active 
expansion of the heart in its diastole may be ascribed to the 
natural elasticity of the organ and the increasing weight of its 
contents, suddenly enlarging its size on the cessation of its an- 
tagonizing systole: neither its structure nor its mode of action 
countenance the notion of a vital dilating power. 

412. Haller and some of his followers ascribed the circulation 
of the blood in part to certain supposed properties of vital attrac- 
tion and repulsion, by which the blood is drawn into, or re- 
pelled from, particular parts, independently of all motion of the 
living solids. These opinions have been recently advocated with 
much ability by Dr. Alison, who considers changes in the vital 
attractions and repulsions to be the chief elements in the process 
of inflammation, as well as in other pathological conditions in 
which the blood and its vessels are mainly concerned.* This 

* See "Alison's Outlines of Pathology and Practice of Medicine," 1843, p. 
122. Several of Dr. Alison's arguments in favour of the existence of ' ; vital 
attractions and repulsions" are founded on certain physiological facts, which he 
considers inexplicable in any other view. It belongs properly to works on phy- 
siology to discuss these matters; but I must own that none of these arguments 
seem to me to be satisfactory. The motion of the sap in the chara and other 
vegetables may be well explained on the principle of exosmosis and endosmosis. 
A fluid of lower density, (water,) physically tends to penetrate and pass into 
membranous tubes, containing a liquid of greater density, (sap:) that which 
begins a flow into the tubes may sustain it in a continued current through them 
so long as the difference in density subsists between the water and sap. A 
similar principle doubtless aids in many cases the motion of fluids in the animal 
body, but many motions of fluids observed in animals (as in the air-tubes, genito- 
urinary passages, &c.) have been traced to the vibrations of cilia, and are no 
proof of the existence of vital attractions and repulsions. 

It is said that when an artery is tied, the blood ceases to run into the open part 
of it, and passes away by adjoining branches, which become enlarged in propor- 
tion, whilst the tied portion becomes empty. It has been supposed that the blood 
here spontaneously leaves the part of the artery through which there is no pas- 
sage. I demur to the correctness of the statement, and still more to the expla- 
nation. Every one who has witnessed great surgical operations must have no- 



INFLAMMATION — NATURE AND PHENOMENA. 209 

hypothesis needs the most ample proof before it can be received. 
It assumes the existence in the fluids as well as in the solids of the 
living body, of properties as distinctive and as peculiarly vital as 
that of contractility or sensibility. It ascribes to these fluids and 
solids powers of attraction and repulsion at sensible distances, 
like the attractions and repulsions of electricity, magnetism, or 
gravitation, yet distinct from all these, and sometimes opposed to 
them. It attributes to the living body a new physical power, 
and almost a discerning intelligence in the exercise of that power. 
Now, before the existence of such a power can be admitted, it 
must be proved that the phenomena of living structures are not 
and cannot be explained, through any known vital or physical 
agencies. We have already adduced and referred to arguments 
and observations to show that the known physical and vital pro- 
perties of the living body will account for the chief phenomena 
of health and disease; and we have now to consider whether the 
same thing may be done with regard to inflammation. If we 
succeed in explaining the nature and effects of inflammation by 
a reference to ascertained properties, it will be needless and un- 
philosophical to assume the existence of others, which are myste- 
rious and unknown. 

413. We have before stated '(§ 408) that inflammation may 
originate either in determination of blood, or in congestion, and 
we now proceed to show that inflammation essentially comprises 
both these morbid elements. The mode in which the process of 

ticed the strong pulsation above the ligature of tied arteries; and the occasional 
occurrence of secondary haemorrhage shows that the blood has no inherent dis- 
position to pass in a new direction. No doubt in time the artery ceases to re- 
ceive blood into its tied portion; but this is because either a coagulum is formed 
where a current cannot pass, or the tonicity of this portion effects the contrac- 
tion of the tube, the force of the circulation being diverted into the contiguous 
enlarged branches. Here is no proof of any self-motory and self-directing power 
in the blood. I have before stated that all my own microscopic observations 
have failed to detect in the blood any spontaneous motions, independent of con- 
tractions of the solids or of currents caused by ciliary motion, exosmosis, and 
endosmosis, and such physical causes. The oscillatory motion said u/have been 
seen by Haller and Kaltenbrunner in the small blood-vessels of inflamed parts, 
"even after the heart is at rest," may, perhaps, be ascribed to the tonic contrac- 
tion of the arteries, which, although gradual in itself, is often seen to act by jerks 
on partially obstructed vessels. A similar oscillatory movement is sometimes 
communicated to capillary vessels by the quivering contraction of adjoining 
muscles. Another observation of Haller mentioned by Dr. Alison, that of "blood 
escaping from vessels between the layers of a living membrane, and neverthe- 
less pursuing its course in a regular stream for a time, even against the influ- 
ence of gravity," may be fairly referred to the vis a tcrgo from the open vessel. 
In the fluids of such a nicely adjusted hydraulic apparatus as the vascular sys- 
tem of animals, and even vegetables, it is surprising how readily motions may 
be produced by various physical causes; and when these motions arc magnified 
by the microscope, it is not wonderful that they should have been mistaken for 
vital movements of the blood itself. 

18* 



210 PROXIMATE ELEMENTS OF DISEASE. 

inflammation has been chiefly studied, is by observing under the 
microscope the effect of irritants on the frog's web. It must be 
remembered, however, that this is only one mode in which in- 
flammation may begin, and we shall afterwards find that cold- 
blooded animals fail to show some of the most remarkable results 
of inflammation. 

The effect, of weak irritants on the vessels of the frog's web 
has been described before, (§ 294, 326.) We then found that irri- 
tation may cause first determination of blood, then congestion; 
these results being dependent on an enlargement respectively of 
the arteries and of the veins. But if a strong irritant (as a 
grain of capsicum, or a minute globule of essential oil*) be ap- 
plied to the web of a frog, all the blood-vessels speedily become 
enlarged: those most irritated are very large and red, and the 
blood in them is stagnant and coagulated: contiguous vessels are 
also very large, but less red, and the motion of the blood in them 
is slow, and often in pulses or oscillations; whilst in vessels be- 
yond, the enlargement of the capillaries is less considerable, and 
the current of blood is very rapid. 

Now, it is obviously the stagnation or tardy motion of the 
blood in the most enlarged capillaries, in the midst of surround- 
ing increased flow, that most characterizes inflammation; and we 
have still to inquire what is the cause of the stagnation. This 
cause must be either in the vessels, or in their blood, or in both. 
The latter we shall find to be the true case. 

414. We have already pointed out (§ 300) that atony and 
flaccidity of blood-vessels may become a cause of impediment to 
a current through them, not by preventing these vessels from 
actively contracting on their contents, (for they have no such 
power,) but by removing that tone by which the vessels maintain 
the calibre and the tension best calculated to transmit onwards 
the force of the current. Vessels thus weak and inelastic, instead 
of equably conveying the current, become distended, lengthened, 
and tortuous in receiving it; and by their very mass, as well as 
by their inelasticity, they partly break the force of the current, 
and partly turn it into other channels. The mode in which this 
results in inflammation will be better understood, if we review 
other local modifications of the circulation in comparison with it. 

In determination of blood, the arteries are enlarged, and so 
are the capillaries in due proportion; the circulation is therefore 
equally increased. In congestion, the capillaries are enlarged, 
without any increase of the arteries: the motion is therefore im- 
paired; but still, being gentle, it may diffuse itself through the 
mass, which moves slowly. But if to congested capillaries there 

• These are preferred because they produce no chemical change in the parts. 



INFLAMMATION — NATURE AND PHENOMENA. 211 

be added the increased and abrupt force of the current from en- 
larged arteries, or if to determination of blood (enlarged arteries, 
§ 326) an atonic congestion of the capillaries be joined, the pro- 
pulsive power of the current will be impaired. As in the experi- 
ment with the intestine, (§ 300,) the blood will pulsate or oscillate 
in the distended vessels rather than pass through them; and the 
main current will pass through collateral anastomosing channels, 
which become the seat of simple determination or increased flow. 
This is just the state of things in the incipient stage of inflamma- 
tion; and if either the capillaries do not speedily recover their 
tone, or the arteries do not contract, the blood in parts becomes 
stagnant, and coagulates, and the obstruction is confirmed. The 
arterial portions of some of the obstructed capillaries are still 
open, and exposed to the pulsative force from' the supplying 
arteries, which continues to strain their coats, and cause an oscil- 
latory motion of their blood particles, but no passage through 
them. Such are the phenomena which we see under the micro- 
scope. 

It may, then, be fairly inferred, that one cause of the stagna- 
tion or retardation of the blood in an inflamed part, is a weak, 
inelastic state of the capillary vessels;* such, in fact, as exists in 
cases of atonic congestion; and on referring to the causes of in- 
flammation, (§ 304,) it may be perceived that many of them act 
by first producing congestion. Nay, we have found (§ 294) that 
even irritants, in some measure, operate in the same way. "The 
continued application of stimuli to a part is sometimes followed, 
not by inflammation, but by congestion. This especially hap- 
pens in the liver, a chiefly venous organ; but it occurs also in 
other parts. It might be supposed that the stimuli act by ex- 
hausting the contractility of the small vessels, and thus leaving 

them weakened and distended by their contents But on 

the application of a strong stimulant, such as a minute drop of 
essential oil, the previous arterial contraction is not apparent, and 
the enlargement is speedy and obvious, causing extreme rapidity 
of motion and enlargement in all the vessels. In a few minutes, 
the size of the arteries begins to diminish, and with it the motion 
in the capillaries beyond them. Many of the capillaries still re- 

* It may, perhaps, be objected that I have supposed a similar state of the arte- 
ries to be the cause of an increased flow through them, and to be the physical 
cause of determination of blood. But this is no objection. The arteries, as com- 
pared with the capillaries, are few in number; their current is rapid; they are 
nearer to the source of power, and are easily supplied from it; when their coats 
lose some of their tone, the pressure of blood into them serves to stretch them 
to tension, and they present even less obstacle to the flow. In capillaries, on 
the other hand, the force is so much distributed, that it is easily disturbed, and 
the motion, naturally tardy, is readily arrested. 



212 PROXIMATE ELEMENTS OF DISEASE. 

tain their enlarged dimensions; in them the motion is most slug- 
gish, and, in some parts, ceases altogether."* 

415. But it is very certain that the obstruction, and much of 
the other features of inflammation, are greatly dependent on 
changes which take place in the blood within the inflamed ves- 
sels. J. Hunter did not overlook this; and, besides describing the 
coagulation of the blood in the most inflamed vessels, he men- 
tions the adhesion of fibrin to their interior. The coagulation of 
the blood in the inflamed vessels was also noticed by Gendrin, 
and others; and Dr. Marshall Hall attributed the obstruction of 
the vessels in inflammation to the adhesion of blood-globules to 
the walls of the vessels. It appeared to me, that microscopic 
observation ought to be directed to this point more specially than 
had hitherto been done; and in 1841, 1 made many careful ex- 
aminations of the early stage of inflammation in the frog's web. 
Some of the results were published in the Medical Gazette of 
July of that year; and as they have been confirmed by several 
other observers, it may be proper to describe them. 

Poiseuille, in his observations with regard to the motionless 
layer of serum which intervenes between the moving blood and 
the walls of blood-vessels, had noticed that the blood particles 
sometimes get into this still layer, and either remain fixed there, 
or move onwards more slowly than the rest of the blood. In 
repeating this observation, Mr. Toynbee and myself remarked 
that it was not the red particles, or elliptical blood discs, that thus 
adhered to or slowly rolled along the sides of the vessels, but the 
white or colourless globules, (§ 212,) called by Muller, lymph 
globules. " I have never seen a solitary elliptical disc adhering 
to the sides of a vessel; and whenever one was arrested in its 
course, it was from its becoming hitched by one or more of the 
adherent round globules. But what appeared to me most remark- 
able with regard to these white globules, was the great difference 
in their number under different circumstances. In young frogs, 
and in those much subjected to experiment, they are always pre- 
sent; but in healthy adult frogs, placed under the microscope with 
as little handling of the web as possible, there were few or none 
to be seen. I have watched, for ten minutes at a time, without 
seeing one: the motionless layer was very thin, but clear, and all 
the blood particles in the larger vessels seemed to move at the 
same rate of speed." It is under these circumstances that the 
effect of irritation or mechanical injury was best seen. " By 
pressure of the finger on the web, partial stagnation was produced 
in many of the vessels; and when this yielded to the returning 
current, the walls of the vessels were seen studded with the white 

* Gulstonian Lectures for 1841; Med. Gaz., July 16, 1841. 



INFLAMMATION NATURE AND PHENOMENA. 213 

globules; whilst many others of the same kind rolled over them 
slowly in the direction of the current. I have before mentioned 
(§ 294,) that a similar result ensued after the web had been sti- 
mulated by capsicum or an aromatic water. Even in the rapid 
flow of blood following these applications, minute globules could 
be seen creeping slowly along the transparent outline of the larger 
vessels; and as the arteries contracted, and the flow through the 
other vessels became less rapid, the number of these globules in- 
creased, their motion became slower, and many adhered to the 
sides of the vessels. If the stimulus used was rather strong or 
long applied, the number of sticking globules was so great as to 
prevent the red particles from passing; and these becoming im- 
pacted in increased numbers, gave to the obstructed vessels a uni- 
form and deeper red colour. When the stimulation was moderate, 
and equally applied to the web, the stagnation usually took place 
first in some of those anastomosing veins in which the current 
is naturally slow and varying in direction; but when a stronger 
stimulus (as an essential oil) was used, the stagnation speedily 
ensued at the point of its application; in fact, unless very minute 
quantities were employed, the stagnation was almost immediate 
and extensive."* 

41 6. I have varied these observations in a great many ways, and 
have always found considerable or continued irritation of the vessels 
in the frog's web to be attended with the appearance and adhe- 

• Med. Gaz., July 23, 1841. I have only recently read a paper by Mr. Addi- 
son, of Great Malvern, published in the Med. Gaz. of Jan. 29th of the same year, 
in which some of the same appearances had been described before I made the 
above observations. The following description is given by Mr. Addison: — " In 
the frog's web, two days after the application of salt, in some of the larger ca- 
pillaries or smaller veins, there are a great number of globules, No. 3," (lymph 
globules;) "and it is quite extraordinary to observe the difference in movement 
between these round speckled globules and the oval ones; the blood globules 
pass in a continued stream, while in the same fluid, in the same vessel, are a 
great multitude of other (lymph, No. 3) globules, which do not move, or do so 
very sluggishly: every now and then they move slowly, apparently urged on by 
the repeated knocks they receive from the blood globules. It would appear, 
that after the capillary vessels have been acted on by the salt, that the round 
(lymph) globules accumulate in an unusual manner, and the blood globules 
repeatedly slide over and knock against them. In some of the vessels, there 
is a rapid stream of blood in the centre, whilst at the circumference there are 
many stationary, round, spotted globules, which do not obey the impulse which 
urges the stream of blood, but remain, or move on slowly by little starts, at un- 
certain intervals, and with unequal pace." This account corresponds very 
exactly with what I have myself observed; but I should not consider the experi- 
ment quite conclusive with regard to inflammation, inasmuch as the chemical 
action of the salt might have been concerned in the production of the lymph 
globules, as salt seems to generate granules in the blood liquor. In my observa- 
ti ii , I was careful to use no stimulus which has any known chemical action 
on the blood. The greater prevalence of lymph globules in the motionless layer 
hail been noticed by Wagner and others; and their more abundant production in 
an intlamcd part has been mentioned by Mr. Gulliver. 



214 PROXIMATE ELEMENTS OF DISEASE. 

sion of the colourless globules; and that when the irritant used is 
at all strong, or frequently applied, many vessels become totally 
obstructed, appear larger and redder than before by the accumu- 
lation of red particles in them, (the blood liquor having passed 
on,) and exhibit to the naked eye all the appearance of inflam- 
matory injection. The chief cause of obstruction seems to be 
comprised in the two circumstances — the increased production of 
the white globules, and their remarkable disposition to adhere to 
the walls of the vessels and to one another; each of these circum- 
stances must be noticed. 

The origin of the white or lymph globules seen in the blood is 
involved in some doubt. They are distinctly spheroidal bodies, 
of a gelatinous consistence, and composed of granules, some of 
which contain nuclei. According to Mr. Addison,* they are 
invested by a delicate membrane, constituting a compound nu- 
cleated cell, which slowly by the action of water, more speedily 
by the operation of solution of potass, bursts . and discharges 
granules and molecules, (nuclei and nucleoli.) In this respect, they 
differ from the blood-discs, which are speedily burst, and are 
almost dissolved by either of these fluids. Dr. Martin Barry has 
endeavoured to prove their identity with the nuclei of the red 
blood-discs; but whatever be their origin or destination, in the 
frog and toad they bear no resemblance to any part of the blood- 
discs, differing altogether in form, colour, and consistence. Mr. 
Gulliver has remarked the same dissimilarity between the white 
and blood particles in the dromedary, lama, and other camelida3, 
and in birds, in which the blood particles are elliptical. It would 
seem more probable that they are formed in the plasma, or blas- 
tema of the liquor sanguinis itself; but whether they grow from 
previously existing molecules or granules, (Addison,) or are 
formed quite spontaneously, cannot now be decided. The sud- 
denness with which they may be produced by irritation or me- 
chanical injury to the web of the frog, would scarcely comport 
with the notion of growth, or of their being always enclosed in a 
cell. The presence of these globules in great abundance, in 
inflamed blood, has been noticed by Gendrin, Gulliver, and others. 
Mr. Addison has particularly observed them in the buffy coat, 
(§ 20S,)t together with numerous bodies of much smaller size, 
(granules and molecules.)! 

417. The peculiar disposition of the white globules to adhere 
to the walls of the vessels is remarkable, and might seem to be 
a vital property. But there are some circumstances which coun- 
tenance the notion that it is chiefly physical. The reason why 
the red particles are more readily carried in the stream appears to 

* Trans, of Provincial Med. and Surg. Assoc, 1843, p. 240. 

f Med. Gaz., Dec. 1840. * Provincial Trans., 1843, hccit. 



INFLAMMATION — NATURE AND PHENOMENA. 



215 



be, that they expose a large surface to the current; and being 
covered by a perfectly smooth, unadhesive membrane, they are 
not liable to stick to the walls. The white globules, on the other 
hand, are' more compact; and although, when in the current, are 
readily carried by it, when more out of it, and in the motionless 
layer, are merely rolled by it, like pebbles by a rapid stream. 
Further, they manifest a distinctly adhesive property, which 
causes them to stick to the walls of the vessels.* In this respect, 

* The accompanying diagram exhibits the appearance of a small portion of 
the capillaries of a frog's web after the application of a grain of capsicum. The 
elliptical blood discs (6) are running in the axis of the vessel, which is much 
narrowed by white globules adhering to the walls, or only slowly rolling along 
them. These globules are speckled with nuclei or granules, refract the light 
strongly, and when rolled on by the current, some of them become pear-shaped, 
from their sticking to the vessel, thus forming a kind of dragging tail, seen very 
well on those marked (a); on altering the focus, globules may be seen adhering 
to the other parts of the vessel. The shaded portion (c) is totally obstructed with 
lymph and blood particles, so impacted together as to form a homogeneous red. 
mass. In such a case I have often seen the particles at (d) exhibit a pulsating 
or oscillatory motion, (corresponding with the action of the heart;) and this, after 
a time, succeeds in breaking down the obstructing mass, which passes away in 
clots, leaving the vessel (c) studded with lymph globules like the other. 




216 PROXIMATE ELEMENTS OP DISEASE. 

they contrast remarkably with the red blood-discs, and the newly 
formed globules of irritated vessels seem to have this adhesive 
property in the highest degree: they are probably without a 
covering. 

418. It seems, then, to be well established, that an essential 
part of inflammation is the production of numerous white glo- 
bules in the inflamed vessels; and that the obstruction of these 
vessels is mainly due to the adhesive quality of these globules. 
The production of these globules must probably be considered as 
an ultimate fact in the history of inflammation and nutrition; but 
it may be observed, that sometimes it seems to be the direct effect 
of an irritant acting on the blood-vessels and their contents, (§ 415;) 
in other instances, it seems rather to result from determination of 
blood into previously congested capillaries, (§414.) Any cir- 
cumstances causing continued determination of blood, where 
congestion is already present, will occasion the production of the 
white globules, and, consequently, inflammatory obstruction may 
ensue. The complete obstruction of some capillaries by coagu- 
lation takes place in all cases of severe inflammation of the frog's 
web; but there are slighter kinds of increased vascularity, in which 
there is no total obstruction, but a continued enlargement of the 
capillaries and veins, as well as of the arteries. This might be 
called simple determination of blood; but it differs from that of a 
transient character, in the motion in the capillaries and veins being 
slower, and in the vast number of white globules seen moving 
slowly in them, (§ 294.) Very probably this kind of process 
takes place in the lowest forms of inflammation, and in increased 
nutrition independent of inflammation. Something of the kind 
is generally seen in the capillary circulation of young frogs. 

419. The foregoing experiments and considerations lead to the 
conclusion, that the most essential character of inflammation con- 
sists in an increased motion or determination of blood to the 
affected part, with a more or less obstructed flow through the 
part: the force of the increased motion being partly expended in 
the arterial portion of the dilated capillaries, (§414,) and partly 
diverted into the collateral channels so abundantly supplied by 
the anastomosis of vessels, (§ 410.) The obstruction in the ves- 
sels of an inflamed part we have found reason to ascribe in part 
to the increased mass in the smaller vessels, and to the diminished 
elasticity of their coats; and in part to the unusual formation of 
white lymph globules., which adhere to the walls of the tubes, and 
to each other. Of the exciting causes of inflammation, the direct 
irritants (§ 402) seem to produce obstruction in both these modes; 
those which act indirectly, (§ 403,) on the other hand, in the first 
instance produce congestion — to which determination of blood 
being subsequently added, the inflammatory process begins: hence 



INFLAMMATION NATURE AND PHENOMENA. 217 

the latter causes, although very common, are not sure of exciting 
•inflammation as direct irritants are. 

420. The effect -of these changes, essent'al to inflammation, is, 
to expend much of the circulating force conveyed by the arteries 
on their capillary terminations; and the enlargement and tortuosity 
of these capillaries, the production of globules which adhere to 
their sides, and their total obstruction by the same means, seem 
to be so many progressive expedients used by nature to direct 
the force of the circulation to that part of the vessels by which the 
process of reparation and nutrition is chiefly carried on. This 
leads us to consider the further changes effected by inflammation. 

421. We have already found that ail inflamed part is the seat 
of determination and of congestion or obstruction. It is this com- 
bination which leads to the changes which characterize inflam- 
mation, and which, in extent, and variety, exceed the changes 
from any other kind of hyperemia. The determination of blood 
to and near the obstructed vessels is attended with the usual re- 
sults of determination, (§ 333, &c.;) but to a greater extent than 
usual, because the cause of determination is more permanent. 
The congestion or stagnation has also its effects, (§ 303, &c.;) but 
more marked and peculiar than usual, because the obstruction is 
more complete than in congestion in general, and because it is 
modified by the influence of a continued force of blood acting 
against it. All these circumstances point out that the natural 
functions of the vessels must be much modified by inflammation, 
and this in different modes in different parts of the inflamed site. 
Thus, in the vessels which are the channels of an increased flow, 
the functions will be more or less exalted or excited; whilst in 
those that are obstructed, vital properties will be more or less 
impaired. It is the approximation of two such opposite condi- 
tions, excitement and interruption of living actions almost in the 
same spot, that render inflammation so seriously destructive to 
structure as well as to function. • 

422. Inflammation at first much exalts sensibility (§ 133) and. 
contractility, (§ 111;) causing tenderness, pain, and spasm. But ■ 
the obstructed circulation may cause a suspension of these pro- 
perties (§ 273) in the centre of the mischief, whilst in surrounding 
parts, the seat of determination, they are exalted. The sympa- 
thetic relations (§ 152, 156) of the inflamed part are also com- 
monly increased. Natural secretions are either suspended by in- 
flammation, or modified by the addition of various modifications 
of the serous and albuminous parts of the blood. This. involves 
the change of nutritive secretion, which is so important and early 
a part of inflammation, that it must bo noticed more fully. We 
shall recur to the other effects of inflammation under the head of 
symptoms. 

19 



218 PROXIMATE ELEMENTS OF DISEASE. 

423. The effusions from inflamed vessels at an early period are 
much the same as those from tense congestion (§ 305-8) and 
determination of blood, (§ 340, 1;) but they commonly occur in 
greater abundance, contain more animal matter, and, as the in- 
flammation advances, they sometimes present appearances not 
met with in the products of mere congestion or determination. 
Thus the effusion at first is a thin serum, causing swelling in 
complex textures, accumulating in the dependent parts of serous 
cavities, or diluting the secretion of the more simple mucous mem- 
branes. But soon fibrin is also effused, part of which may con- 
crete mto coagulable lymph, or still remains dissolved, as in the 
liquor sanguinis. Thus an inflamed pleura becomes coated with 
a film of lymph; and the clear fluid effused into, the sac, when re- 
moved from the body, sometimes spontaneously separates into a 
fibrinous clot and scrum. This occurring in complex textures 
gives a hardness to their swelling, as in phlegmon of cellular 
membrane, hepatization of the lung, &c. In mucous membranes, 
there may be thickening of the submucous texture, and the mu- 
cous secretion becomes unusually viscid. 

424. The microscope has given much additional information 
on the nature of inflammatory effusions, although it lias yet left 
many points in uncertainty. In the frog's web, after inflamma- 
tion has continued some hours, there appear outside of the vessels 
(especially those in which the strongest current encounters the 
most complete obstruction) white globules or corpuscles, with 
specks in them, exactly like the lymph or nucleated globules 
within the vessels, (§ 415.)- These are also found in various in- 
flammatory effusions, and are called exudation globules or 
fibrinous globules. Mandl supposes them to be merely conso- 
lidated globules of fibrin, and states, that the liquor sanguinis may 
be seen to coagulate in similar globules on the glass of the micro- 
scope. But these have been described by Gerber as mere albu- 
minous granules, without nuclei, and quite unlike the true exuda- 
tion corpuscle. So, also, from the recent observations of Mr. 
Gulliver* and Mr. Addison,! it appears, that fibrin consolidates 
in extremely fine threads or fibrils interlacing each other. Both 
these observers describe the nucleated or granulated corpuscles 
as occurring among these fibres, together with more minute 
granules and molecules, (nuclei and nucleoli,) which appear to 
be similar to those which compose the corpuscles. Now, all 
these bodies appear in inflammatory effusions, although they 
occur in very various proportions, and present different modifica- 
tions. The following are the chief of these elementary solids of 
inflammatory effusions. 

* Note to Gerber's General Anatomy, p. 31. 
f Med. Gaz., April 15, 1842. 



INFLAMMATION NATURE AND PHENOMENA. 219 

1. Molecules, immeasurable from minuteness, each appearing 
as merely a dark speck. [Smaller primitive molecules; Gruby.) 

2. Granules, (Gerber, Addison,) measuring from T1 foo to foW 
of an inch, appearing as a light spot, surrounded by a dark circle. 
[Larger primitive molecules, Gruby. Disks, Barry.) 

3. Fibrils, extremely line, forming the chief solid of fibrine, 
and the burly coat of the blood. 

4. Lymph or exudation corpuscles, measuring from -goVo *° 
T i-o- of an inch, (Gulliver,) composed of granules and molecules, 
(nuclei and nucleoli,) and sometimes enveloped in a cell. 

Pus globules appear to be enlarged modifications of the last; 
and so are globules of mucus, and which, with nucleated epithe- 
lium particles, are commonly found in the effusions from mucous 
membranes. Yellow tuberculosis matter has been distinctly 
proved by the researches of Gerber, Gulliver, and Addison, to 
consist of disintegrated or degenerated exudation corpuscles, or 
granules. 

425. Of these elementary solids, the fibrils certainly may form 
from the effused liquor sanguinis out of the vessels, and even 
removed from the body, (Addison;) but it is a question whether 
the others concrete spontaneously from the liquid fibrin, or grow 
from germs, (molecules or granules,) disseminated from the 
vessels or adjoining textures. The close resemblance of the 
exudation corpuscles and their contents to the white globules and 
granules, so abundantly produced in the blood of the inflamed 
vessels, would seem to indicate their identity; but it is not easy 
to understand how they pass through the walls of the vessels, in 
which no pores are visible under the highest magnifying powers. 
Mr. Addison has, indeed, represented the white globules as first 
passing into the substance of the wall of the blood-vessel, and 
then beyond it; but this would seem too slow a process. It 
would appear more probable cither that nuclei or molecules, too 
small to be discernible, do pass out in this way, and then grow 
and propagate compound granules, (lymph and pus corpuscles;) 
or that these corpuscles arc formed by coagulation in the effused 
liquor sanguinis as the fibres of fibrin certainly are. 

426. These solid products of inflammation, when they cohere 
and grow into nucleated cells and fibres, arc the plastic materials 
of which new membranes and textures arc formed: when they 
remain detached, and swell into larger globules, or split into 
irregular granules, or cohere imperfectly and shrink without 
developing cells, they form the aplastic materials of purulent, 
tuberculous, and kindred products, which Gerber therefore calls 
" degenerated exudation corpuscles."* As wc shall have to 

* This statement, which is founded on the recent microscopic observations of 



220 PROXIMATE ELEMENTS OF DISEASE. 

notice these further under the head of results of inflammation, 
we shall now return to the process of inflammation and its ac- 
companying phenomena. 

427. Inflammation is always attended with more or less effu- 
sion. Where the inflammation is slight, this effusion may re- 
move it by unloading the engorged blood-vessels; but where the 
inflammation is more intense, that is, where the obstruction is 
considerable and the determination of blood strong, the effusion 
may go on to a great extent without resolving the inflammation. 
It is then that the more serious effects of inflammation result. 
The effused matters press on and pervade the adjoining textures, 
injure their nutrition, and impair their cohesion; and thus takes 
place the softening of textures, which occurs chiefly in those of a 
complex kind, which retain the effused matter. The continued 
obstructions in the inflamed part leaves the veins and lymphatics 
free to absorb, and the high pressure and determination of blood 
tend rather to promote this process of absorption. Hence, as new 
matters are effused, the old texture is compressed, disintegrated 
and absorbed; the finer exudation corpuscles and fibres them- 
selves are removed or altered, and the large pus globules alone 
remain: this is suppuration. Or if the original obstruction of 
the inflamed vessels be extensive, or have been rendered so by 
the subsequent effusion, the supply of blood may be so stopped 
in a part, that it dies, and the dead part may then either be only 
dissolved and absorbed at its circumference, and separated from 
the living textures m form of a slough; or if more extensive, the 
dead part may pass into decomposition before it can be separated, 
and thus occur gangrene and sphacelus. If the inflammation be 
of a lower kind, the obstruction less complete, and the effusion 
more gradual, the nutrition of the natural texture is only impaired, 
not arrested, and from the increased deposition of solid matter, 
induration or consolidation takes place. 

SYMPTOMS AND EFFECTS OF INFLAMMATION. 

428. We have described the process of inflammation in its in- 
timate nature and phenomena; we have now to notice its more 
obvious effects on function and structure, which become symp- 
toms of its existence. These symptoms may be divided into 

Gerber, Gulliver, Addison, Watt, and others, is a remarkable confirmation of views 
on the nature of pus and tubercle which I have entertained for the last twenty- 
years, and to which I adverted in the following sentence, published fifteen years 
since: — " I am myself disposed to consider tubercular matter, pus, and coagulable 
lymph, only as varieties of the same albuminous matter that exists in the blood, 
and differing from each other rather in mechanical condition and consequent 
capability of organization, than in chemical composition." — Rational Expos, of 
Physical Signs of the Diseases of the Lungs and Pleura. 1828. p. 159. 



INFLAMMATION SYMPTOMS. 221 

local and general; the local occurring chiefly in the part which 
is the seat of inflammation; the general affecting the system at 
large. 

LOCAL SYMPTOMS. 

429. We have before remarked that the local symptoms are 
commonly more prominent, and the first to occur, when inflam- 
mation is excited by local irritation, (§ 402,) and the fever which 
afterwards supervenes may even disguise the local symptoms. 
The chief local symptoms have been already mentioned in the 
definition, redness, heat, pain, and sivelling, to which may be 
added various disturbances of the function of the part affected. 
We shall explain and illustrate these symptoms. 

430. The redness of an inflamed part is obviously due to the 
increased quantity of blood in the vessels. All these vessels are 
much enlarged, so that they receive many more red particles than 
usual; and the finest capillaries, which commonly are invisible 
from their admitting only the liquor sanguinis with now and then 
a red particle, are now distinctly coloured from the number that 
pass into them. Some observers have thought that new vessels 
are formed by the blood forcing its way through the textures. I 
have never seen this in the frog's web; but it appears to take 
place in some textures which are not naturally vascular, such as 
the anterior part of the cornea, and cellular cartilage, (Toynbee.) 
But the microscope shows that besides the augmented size of the 
blood-vessels which convey blood, much of the redness of inflam- 
mation arises from the vessels in which the blood is stagnant. 
The colour of these is much more red than that of the vessels 
through which a current still passes; and this has before been 
referred to an accumulation of colouring matter, which takes 
place in them, (§ 415, 417, note.) These vessels appear so im- 
paeted to their outmost limits with colouring matter, that the 
shape of the blood-disks and of the white corpuscles is no longer 
discernible: yet these are still present; for when an obstructed 
vessel re-opens, the red mass breaks up into clots and particles, 
and many white corpuscles are left sticking to its walls. (See 
note, p. 215.) It is obvious, therefore, that the obstructed vessels 
become stuffed, as it were, with red particles, the liquor having 

1 on. In many instances, too, it may be seen that the red- 
ness of an inflamed part is augmented by spots and patches of 
e\ii i v.is.ited blood, which prevail especially in some varieties of 
inflammation. 

The redness of inflammation presents great varieties according 
to the aumber and distribution of the capillary vessels of the part; 
hut its most essential seat being in the capillaries, its most con- 



222 PROXIMATE ELEMENTS OF DISEASE, 

stant character is a diffused or capilliform redness. This is com- 
monly far more vivid and general in the living than in the dead 
body. In the skin and mucous membranes during life, it is often 
seen as a uniform blush of colour, varying from a delicate pink 
to a bright crimson. After death this blush has sometimes en- 
tirely disappeared; but commonly more or less of it remains; and 
on examination with a lens, it is found to consist chiefly of nu- 
merous vascular striae, network, or points, with here and there 
larger vessels and ramifications also injected. But the large ves- 
sels (veins) are distended much less generally than in congestion, 
(§ 280,) and the redness is therefore less arborescent and rand- 
form. To explain the reason of the disappearance of inflamma- 
tory redness after death, we must bear in mind that much of it 
depends on determination of blood, (§ 326,) which is maintained 
by the action of the heart, distributed by the arteries; and that 
when this ceases in death, the tonic contraction of the arteries, 
which survives for a few hours, expels the blood from the ves- 
sels, (§ 120.) A similar effect is sometimes produced during life, 
by cardiac syncope. The redness that remains after death seems 
chiefly to consist of the vessels which have become totally ob- 
structed and impacted with blood, or have long congested and 
have lost their tone, (§ 295.) This furnishes us with a useful 
means of distinguishing in different cases the comparative preva- 
lence of the elements of inflammation. Thus in cases in which 
the redness disappears after death, we may know that the pre- 
dominant element was local determination of blood (§409) with- 
out much obstruction or permanent congestion. This is observed 
in erythematic and diffused membranous inflammations, the cuta- 
neous inflammations of eruptive fevers, and the early stages of 
all inflammations excited by moderate local irritation, (§ 402, 
415.) On the other hand, if much redness remains after death, 
we may infer that obstruction or congestion of the vessels has 
existed to a great extent. This happens especially in phlegmo- 
nous inflammations, those of parenchymata, and others which 
have advanced to a certain intensity, and those which have 
originated in congestion, (§ 403.) 

The florid hue of the redness is also during life a sign of the 
predominance of determination, for it shows that the blood is 
chiefly arterial and not stagnant. Where congestion prevails, or 
where the blood has been long stagnant in many vessels, the 
colour is deeper; but it is rarely so deep as in pure congestion, for 
the presence of white globules tends to lighten it or give it a 
brownish tinge. In the dead body these distinctions are not 
equally available, for the arterial part of the blood may have been 
removed by the contraction of the vessels, or darkened by stagna- 






INFLAMMATION — SYMPTOMS. 223 

tion; and the livid portions speedily become florid on exposure to 
the air.* 

The progress of inflammation modifies the redness. The colour 
becomes more florid and deeper as the inflammation advances to 
its acme; it then becomes either livid before it subsides, or paler 
from the colour of the effusion. In complex textures, the effused 
lymph or pus changes the redness to pink, flesh colour, drab, or 
yellow. 

431. The heat of hiflammation is obviously dependent on the 
increased flow of blood through the part; and it may be con- 
sidered the representative of the amount of determination of 
blood concerned in the inflammation. Hence it is great in ex- 
tensive and active inflammation, and is generally proportioned 
to the florid redness or arterial vascularity. "It is uncertain 
whether the high temperature of an inflamed part is caused by 
the augmented changes going on in that part, or whether it arises 
merely from the greater quantity of warm blood which passes 
through it. John Hunter made some observations to determine 
this point, and never found that the temperature of an inflamed 
part was raised above that of the interior of the body, which it 
might be expected to be if inflammation was in itself a calorific 
process. That extensive inflammation raises the heat of the 
whole body, as well as of its own site, is quite certain; but this 
may be simply by causing general excitement, especially of the 
circulation and respiration, and by repressing the perspiration 
and other exhalations, by which the body is naturally cooled. 
Increased heat is a very important and valuable symptom of in- 
flammation, since it is more constantly discernible than any other, 
and serves to distinguish inflammation from congestion and ner- 
vous irritation, which may resemble it in other symptoms. But 
to indicate inflammation the heat must be continued, and not 
merely coining in flushes with simple determination of blood. 
Generally the skin is dry as well as hot: but it may be per- 
spiring, and yet a temperature, higher than natural, may be sus- 
tained. 

432. The swelling of an inflamed part is caused in some de- 
gree by the enlargement of the vessels, but chiefly by the effu- 
sions from them, and will be therefore proportioned to the amount 
of these: but the situation, form, and degree of the swelling will 
also greatly depend on the natural structure of the part inflamed. 
In serous membranes, the vessels being comparatively few, ad- 

* I have often in the dead-house seen mere congestive redness mistaken for 
inflammatory, because it was florid, from the action ol'tlie air, or from the tians- 
lucence of a subjacent white structure. Frequently, too, the claret slain of 
arteries and intestines is mistaken for in (lam matory redness: a common lens 
will prove it to be not so, by showing that it is not vascular. 



224 PROXIMATE ELEMENTS OP DISEASE. 

mit of but little enlargement; and the effusions, not being retained 
by complexity of structure, soon overflow externally and chiefly 
accumulate in the most dependent parts of the serous sac, causing 
dullness on percussion, and sometimes fluctuation in the chest and 
abdomen, and when in large quantity distending these cavities. 
Mucous membranes are more vascular and complex in structure: 
hence the enlargement of vessels early causes some thickening; 
but the swelling is chiefly due to interstitial effusion in the sub- 
mucous tissue, (so manifest in coryza and cynanche:) this effu- 
sion, when merely serous, soon passes off in the thin flux which 
attends catarrhal inflammations, and the swelling may subside 
with it: when the effusion is more solid, the swelling remains 
longer, is attended with a more viscid secretion, and subsides only 
when this secretion becomes opaque, and somewhat fat in its 
composition. The skin presents great variety in the swelling as 
well as in the redness caused by inflammation. Sometimes the 
swelling is diffused and hard, as in cutaneous erysipelas. In 
urticaria the same hard swelling occurs in spots or patches, and 
the effusion in parts supersedes the vascular redness, causing 
white centres or wheals. In tubercular inflammations of the skin 
the redness and swelling are still more circumscribed, and the 
effusion seems to be chiefly solid. In papulae the swelling is even 
more minute and confined to a point. In blebs and vesicles, the 
effusion is between the cuticle and the true skin, and the swelling 
is confined to corresponding patches or small spots. Inflamma- 
tion of cellular texture is attended with considerable swelling; this 
being diffused, oedematous, and pitting on pressure, when the 
effusion is serous, being more tense when there is fibrin with the 
serum; and being hard and subscribed (as in phlegmon) when the 
matter effused is chiefly fibrin. Parenchymatous organs, in like 
manner, are remarkably swelled by inflammation. The liver, 
kidneys, testicles, lymphatic and other glands, attain a large size 
from the mere distension of their blood-vessels; and we have 
noticed a similar result from mere congestion, (§ 293;) but inflam- 
mation does not last long in these structures without causing effu- 
sion, which, by various proportions of serum and lymph, may 
cause swelling, differing in its firmness. The lungs, from their 
porous structure, do not swell materially in bulk; but the effusion 
displaces the air in their cells, thus increasing their weight, and if 
the effusion aboimd in lymph, converting them into a more or less 
solid mass, like liver, (hepatization.) 

433. The pain of inflammation is caused by that exaltation of 
sensibility (§ 135) which determination of blood produces, (§ 333,) 
often increased by the tension or pressure arising from the swell- 
ing. The amount of pain will therefore depend much on the 
natural sensibility of the part, the degree in which determination 



INFLAMMATION SYMPTOMS. 225 

of blood predominates, and the tension or pressure induced. The 
severest pain arises where these circumstances co-operate, as in 
inflammation of the pulp of a tooth, the sheath of a nerve, the 
lining of a bony canal, as the auditory meatus, &c. • In most cases 
pain is chiefly felt when the inflamed part is pressed or stretched, 
constituting excessive tenderness. Thus the pain of perito- 
nitis is felt on pressing the abdomen, or on straining the walls by 
coughing or vomiting: the stitch of pleurisy is felt on taking a 
full breath: the pain of external inflammation and rheumatism, 
on motion or pressure on the limbs. In enteritis there may 
be little pain until the intestines become spasmodically contracted 
in some parts, and distended in others, by flatus and other con- 
tents: hence the pain may vary, whilst the inflammation remains 
the same. Parenchymatous organs and mucous membranes 
being comparatively soft and yielding in texture, are not the seat 
of much pain, when inflamed. In the early stage, pain, with 
heat, may indicate the activity of inflammation, that is, the pre- 
valence of determination of blood. In the more advanced stages, 
the pain rather bears relation to the amount of tension from 
swelling or effusion, and is commonly relieved when this becomes 
more diffused, or ends in suppuration. 

434. Besides pain and tenderness, sensibility, increased by in- 
flammation, sometimes exhibits other modifications, such as feel- 
ings of soreness, tingling, heat, itching, &c. Peculiar sensations 
are also excited in the organs of special sense when they are in- 
flamed, such as noises in the ears, painful and disturbed vision, 
&c. The peculiar sensibility which excites the motions of sneez- 
ing, coughing, vomiting, micturition, and defecation, is exalted, 
when respectively the Schneiderian membrane, the lining of the 
upper part of the air-tube, the cardiac end of the stomach, the 
bladder, and the rectum, are inflamed. Other sympathetic sensa- 
tions excited by inflammation are peculiar to disease, as the pain 
in the shoulder-blade, with inflammation of the liver; pain in the 
testicle, with inflammation of the kidney; pain of the glans penis, 
i j i inflammation of the bladder; pain of the knee, with inflam- 
mation of the hip. 

435. Contractile fibre is not itself prone to inflammation; when 
the parts contiguous to it are inflamed, the effect is commonly 
first to increase its irritability, and subsequently to impair it, pro- 
bably by exhaustion. Thus the heart, when its membranes are 
inflamed, acts first with great force and frequency, but subse- 
quently with feebleness and irregularity. When the intestines, 
bladder, or air-tubes are inflamed, there is contraction followed 
afterwards by more or less weakness of the muscular fibres of 
these parts. 

480. Other functions arc somewhat similarly affected under 



226 PROXIMATE ELEMENTS OP DISEASE. 

the influence of inflammation. In inflammation of the brain and 
its membranes, there is commonly at first, more or less excite- 
ment of the sensorial functions, causing delirium, hallucinations, 
and convulsions: afterwards ensue stupor and coma, and paraly- 
sis. In the early stage of inflammation of the spinal cord, there 
may be tetanic convulsions; afterwards follows paralysis. Often 
symptoms of partial excitement are conjoined with others of in- 
terruption of function; and this is not extraordinary, seeing that 
inflammation comprises diminished as well as increased flow of 
blood, and the former generally predominates as the inflamma- 
tion advances and effusion proceeds. Inflammation of the lungs 
causes dyspnoea: that of the stomach interferes with digestion: 
inflammation of the kidneys suspends or impairs their secreting 
power, &c. It is needless to go into further details. 

CONSTITUTIONAL SYMPTOMS OP INFLAMMATION. 

437. The irritation of inflammation frequently extends itself 
to the system at large. The functions of the Avdiole body are 
disordered. The contractions of the heart are more frequent and 
forcible than usual: the arterial tonicity is increased, (§ 121;) 
hence the pulse is quick and hard: the skin is dry and hot: the 
appetite and strength arc impaired: and the natural secretions are 
diminished and otherwise disordered. This is inflammatory 
fever. 

438. Among the most important general effects of inflamma- 
tion must be noticed the change in the condition of the whole 
blood. We have before noticed, that there is an excess of fibrin 
and of the colourless globules in the blood in inflammatory dis- 
eases, (§ 195;) and that the separation and contraction of this fibrin 
(§ 203, 4) takes place in an unusual degree, and produce the pe- 
culiar buffed and cupped appearance of the clot so remarkable 
in inflamed blood, (§ 208.) This excess and separation of 
fibrin displayed in the buffy coat is commonly proportioned to 
the extent of the inflammation and its duration in an active state. 
This would suggest that the change in the blood is altogether 
produced in the blood-vessels in and near the inflamed part; and 
that the increased development of white globules, seen by aid 
of the microscope, (§ 415,) is a kind of demonstration of this pro- 
duction. This supposition derives support from the fact, that 
blood drawn directly from an inflamed part is more buffed than 
that drawn from a distant part.* The excess and separation of 
fibrin is more remarkable in inflammations of serous membranes 
than in those of mucous membranes, or parenchymata, which 

* I have observed this even in blood drawn by cupping, on a part inflamed by 
the previous application of a blister. 



INFLAMMATION — SYMPTOMATIC FEVER. 227 

may perhaps be ascribed to the former inflammations being at- 
tended with less local vascular distension and overflow of the exu- 
dation globules and fibrin. Acute rheumatism presents the highest 
degree of the buff and cupping of the blood; perhaps because 
the inflammatory irritation arising from matter in the blood itself* 
(§251) affects a great many vessels, yet without completely ob- 
structing them, so that determination of blood predominates over 
congestion; and although there may be much inflammation and 
effusion of the early kind, (§ 423,) this does not lead to suppura- 
tion, or other of the more destructive changes which follow in- 
flammation. It has been before mentioned, (§ 245,) that an in- 
creased activity of circulation and respiration might contribute to 
augment the fibrin of the blood in acute rheumatism and other 
inflammations not impairing the respiratory function; but it was 
then objected, that the increase of the fibrin is sometimes observed 
in rheumatism without much acceleration of the pulse and breath; 
and, on the other hand, in fevers in which the pulse and breath 
are much hurried, the fibrin of the blood is even diminished, 
(§ 196.) And it was found, by Andral and Gavarret, that in fe- 
vers, the occurrence of local inflammation always caused an in- 
crease of the fibrin in the blood. 

It seems pretty clear, then, that the increase of fibrin, and its 
more contractile and separating quality, originate in the vessels 
of the inflamed part, and must be regarded as an augmentation 
of' the vital process of nutrition developed by inflammation. A 
similar augmentation takes place in the vessels of the uterus dur- 
ing pregnancy, when the blood drawn generally exhibits a buffed 
appearance; and although such ah appearance is not commonly 
presented by blood drawn from fast-growing children during 
health, yet in them it is very readily induced by inflammation, 
and the plastic products are unusually copious. It has been 
mentioned, (§ 415,) that in young frogs, even in health, many 
white globules are seen in the blood-vessels adhering to or mov- 
ing slowly along their sides; and this appears to be a proof of the 
activity of the same nutritive or plastic process which is exalted 
to its highest degree in acute inflammation. 

439. It has been supposed that the inflammatory or fibrinous 
state of the blood is the cause of the general excitement consti- 
tuting the symptomatic fever accompanying inflammation; but it 
may I >e objected, that this fever frequently rises high before the 
blond lias begun to exhibit the bully coat, often subsides when 
the bully coat is most abundant, and is sometimes wholly absent 
when the blood is both bulled and cupped, as in subacute rheu- 
ln.iiisni. li is vi t\- probable, however, that the excess of fibrin 

• The traded appearance of the blood in inflammatory dropsy admits of a 
similar interpretation, (§ 385.) 



228 PROXIMATE ELEMENTS OF DISEASE. 

may contribute to the excitement; and it certainly materially 
affects the duration and the products of the inflammation. 

' 440. In inquiring into the pathology of inflammatory fever, 
we must bear in mind, that it sometimes precedes the distinct 
development of the local inflammation, being, in fact, a general 
excitement or reaction after the disturbing influence of the ex- 
citing cause. This is especially the case where inflammations 
are produced by cold, fatigue, and other causes which first induce 
congestion, (§ 403.) The operation of these causes is at first 
depressing to the whole system; and the continuance of this marks 
the cold stage of the fever, with weak pulse, coldness of the ex- 
tremities and surface, general pallor, various uneasy feelings, 
dejection of spirits, and depression of strength. Afterwards ensues 
the reaction, beginning with rigors, accelerated pulse and breath- 
ing, sometimes vomiting, or other functional disturbances: soon 
the skin becomes hot, the pulse hard, as well as frequent; uneasy 
feelings in the head, back, and limbs, are experienced, with thirst, 
loss of appetite, restlessness, and much weakness. It is during 
or after the establishment of this reaction that the local symptoms 
of inflammation may become prominent. During the cold stage, 
they may have been chiefly those of congestion of the affected 
organ, (§ 303,) impaired function, With more or less uneasiness; 
but now pain, (§433,) heat, (§ 431,) and various symptoms of 
local irritation, (§ 434,) ensue; and frequently, as these become 
developed, the general disturbance is less complete. In eruptive 
fevers, the general disturbance and functional disorder is greatest 
before the eruption (or local inflammation) appears. In inflam- 
mations from cold or fatigue, the first disorder sometimes re- 
sembles that of continued fever, which is changed for simple in- 
flammatory fever as soon as the inflammation is pronounced. In 
other cases, again, chiefly those which originate from local irrita- 
tion, (§ 402,) the inflammation is developed, and its symptoms 
are prominent, before the symptomatic fever is excited. Gene- 
rally the fever is in proportion to the severity or active character 
of the inflammation; and if it were always so, we might conclude 
that the fever is the result of a reaction from the disturbance of 
the circulation produced by the inflammation; but we sometimes 
find inflammation of trifling organs, such as the tonsils, attended 
with a very smart fever; and much greater disturbances of the 
circulation, such as congestions of the lungs and liver, take place 
without causing any fever. It seems more probable, then, that 
the fever accompanying inflammation arising from local irrita- 
tion, is caused by an exciting influence propagated from the in- 
flamed part to the heart and arteries through the medium of the 
nerves. The same influence also sustains the inflammatory fever 
in the cases before noticed in this paragraph, in which the first 
febrile movement seems to be the result of reaction. 



INFLAMMATION SYMPTOMATIC FEVER. 229 

441. It still remains unexplained why, in fever, the circulation 
and some functions are excited, whilst others, as secretion, mus- 
cular strength, and the appetites, are much impaired. We cannot 
entirely solve the difficulty; but we may point out that the ex- 
citement is not one of a healthy kind, being attended with an 
excessive tonicity of the arteries, (§ 121,) which is the cause of 
hardness of the pulse, and which may transmit the blood through 
the capillaries too rapidly to permit of its proper changes by 
excretion. It is also possible that the vital powers of secretion 
(§ 158) may be more directly impaired by the inflammation or 
its cause; for it is certain that, either as cause or effect, imperfect 
secretion is one of the most prominent elements of fever in gene- 
ral. Thus the bowels are generally costive; the urine scanty and 
high coloured; the skin dry; the tongue clammy, with thirst; and 
ulcers or sores, that may have been discharging before, now be- 
come dried up. So, too, on the subsidence of the fever, all these 
secretions are restored. 

443. The fever accompanying inflammation is generally high 
— that is, attended with hard pulse, hot skin, and general excite- 
ment — in the young, the sanguine, (§ 38,) and plethoric, (§ 279;) 
those, in short, in whom the vascular system is naturally active, 
(§ 401.) On the other hand, it is commonly low — that is, with 
weaker, though sharp and quick pulse, less general heat of skin, 
and with tongue more foul, and functions often rather oppressed 
or disordered than excited — in persons of phlegmatic tempera- 
ment, (§ 40,) and in those weak from age, disease, mal-nutrition, 
intemperance, or confinement. The type or character of the fever 
also varies with the seat of the inflammation, and the particular 
textures affected, although the variation is less constant than it is 
generally represented to be. It is commonly stated, that the fever 
is high in inflammations of most serous and fibrous textures, 
and in phlegmonous inflammation of cellular texture; that it is 
low in inflammation of the stomach and intestines, kidneys, large 
joints, and in diffuse inflammation of the cellular texture; and 
that the fever is of an intermediate character in inflammation of 
mucous membranes and parenchymata. Clinical experience how- 
ever shows that there are many exceptions to these statements; 
and where the type of the fever is affected by the texture, it is 
chiefly by the intensity of the inflammation and the nature of its 
product. Diffused inflammations, of little intensity, often excite 
very little fever, and few local symptoms. The reverse is the 
case of very acute inflammations even of moderate extent. 

4 13. The exciting cause, or some co-operating influence, often 

materially affects the type of the fever. The inflammation occur- 

iir_ r after serious accidents or burns is often attended with a low 

fever, the reaction being imperfect from the continued depressing 

20 



230 PROXIMATE ELEMENTS OP DISEASE. 

influence of the cause. The same remark is applicable to the case 
of inflammation from poisons, which are locally irritant, but se- 
dative to the system. Even the long operation of cold may so 
depress the vital powers — especially that of the heart (§ 75) — that 
the reaction is imperfect, and the fever is low: thus, in very incle- 
ment seasons, inflammations are often attended by a typhoid or 
adynamic form of fever, (§ 25.) 

444. In the lower forms of inflammation, (§ 442,) the fever 
may be remittent or even intermittent: a state of depression al- 
ternating with a state of excitement, ending with perspiration; 
and when inflammations become chronic, or are of slight cha- 
racter, they may excite no fever at all. They generally, however, 
induce some constitutional disorder, in which defective excretion 
(§ 171) is commonly a predominant element. When it is borne 
in mind that inflammation includes determination of blood, it 
will be obvious that, besides the irritation connected with it, 
there may be more or less exhaustion of other parts of the body, 
(§ 331:) the part inflamed being over-supplied with blood, other 
parts are in want. This effect is most obvious in anaemic and 
debilitated subjects; and to it must be ascribed the weak circu- 
lation, coldness, disordered functions, and gradual emaciation of 
the body in general, when a part long suffers from low inflam- 
mation. 

NATURE AND SYMPTOMS OF THE TERMINATIONS OR RESULTS 
OF INFLAMMATION. 

445. The results or events of inflammation may be compre- 
hended under four heads: Resolution, Effusion, (including ad- 
hesion,) Suppuration, (including ulceration,) and Gangrene. It 
must not be supposed that these often occur quite singly, or that 
they are separated from each other by a very marked line; but 
these terms are conveniently attached to those results in which 
each respectively predominates. 

Resolution consists in the cessation of the inflammation, and 
the speedy removal of any slight effusion. As the essential parts 
of inflammation appear to be determination of blood, with ob- 
struction to its flow through some vessels; so the resolution of 
inflammation consists in the yielding of the obstruction and the 
subsidence of the determination, the vessels contracting to their 
normal dimensions. This may be well seen under the micro- 
scope. Sometimes nothing remains of the inflammation, but 
more or fewer of the white globules adhering to the sides of the 
vessels; but more commonly some vessels are still obstructed, 
and others congested, with the motion in them slower than usual, 



INFLAMMATION RESULTS RESOLUTION. 231 

the determination of blood (enlargement of the arteries) having 
ceased. So commonly, we find congestion remain in a part that 
has been inflamed; and not unfrequently a flux or watery effu- 
sion may result from that congestion, (§ 375.) 

446. Resolution of inflammation may occur spontaneously in 
slight cases; or in consequence of treatment; or from the inflam- 
mation being transferred to another part. Some inflammations 
creep to adjoining parts, as in the case of erysipelas and some 
serpiginous cutaneous eruptions. Others affect similar textures 
in different parts of the body; and being resolved in one part, 
appear in another: this happens in rheumatism, which affects 
fibrous textures, and is transferred from limb to limb, or joint 
to joint, by what is called metastasis, or translation. This may 
be fairly traced to the mobility of the peculiar materies rnorbi, 
(§ 402,) the cause of the inflammation. A remarkable metas- 
tasis of resolving inflammation is sometimes seen in parotitis, 
the breast or the testicle becoming the seat of the new attack. 

447. The occurrence of resolution is marked by a subsidence 
of the chief symptoms of inflammation: first, of the heat and 
pain, and, more gradually, of the redness and swelling. The heat 
usually yields to perspiration. The pain becomes gradually 
easier: and in some parts, as the skin, may pass into itching 
before it subsides. The redness sometimes simply fades; more 
commonly it becomes less florid, and may pass through shades 
of a livid or dusky hue before it vanishes. The swelling soon 
subsides; the effused, fluids being so speedily removed by absorp- 
tion, that effusion can scarcely be said to have been a result. 
Still, in some instances, congestion, or some of its results, (§ 274, 
350,) or nervous irritation, (§ 126, 152,) remains behind after the 
inflammation has ceased. 

448. The resolution of any considerable inflammation is 
marked by a reduction of the fever: the pulse becoming softer 
and less frequent; the skin moist with perspiration, sometimes 
profuse; the urine, becoming more copious, abounding in urea, 
and depositing, as it cools, a plentiful, lateritious, or branny 
sediment, consisting of lithate of ammonia. The constancy of 
this last change on the decline of inflammatory fever has led to 
the supposition that it is critical, and determines the removal of 
the disease. The lateritious sediment in the urine is a pretty 
certain symptom of the subsidence of fever, and of the amelio- 
ration at least of the inflammation which excited it; but it is 
uncertain how far it is the cause or the effect of the improvement. 
It indicates an increased excretion of the solid constituents of the 
urine; for there is often an excess of urea as well as of the lithates; 
and comparing this With the scanty secretion of urine during the 
febrile excitement, and the decay of tissues which is always 



232 PROXIMATE ELEMENTS OF DISEASE. 

taking place, (§ 254,) we can scarcely avoid the conclusion that 
these excrementitious matters had been accumulating in the blood 
from the impaired function of the kidneys during the fever; and 
that now, as the fever subsides, and their function is restored, the 
accumulated matter is thrown off. Now, although the function 
of the kidney must be first impaired to cause the accumulation 
of the excrementitious matter in the blood, yet this matter so re- 
tained tends to keep up the disorder, (§ 6S, 171;) and it is by 
means which promote the elimination of this matter that we 
succeed best in reducing febrile excitement. So, likewise, in cases 
where the function of the kidneys is permanently impaired by 
Bright's disease, (congestive degeneration, § 309,) inflammatory 
and other fevers are not readily brought to a termination: persons 
so affected are said to be "bad subjects," with " broken-down 
constitutions;" and they often sink because their excreting organs 
are unequal to the increased task thrown on them. In cases in 
which the resolution of the inflammation is only partial or imper- 
fect, a daily remission or alleviation of the fever may take place; 
and with it there is usually a deposit in the urine, of a pinker or 
lighter colour than the usual brown lateritious sediment, and con- 
taining, besides lithate of ammonia, purpurate of ammonia and 
lithate of soda. 

Effusion [including adhesion). 

449. Effusion we have already found to be a result of inflam- 
mation, (§ 423;) but it is not always, like resolution, a termination 
of this process, (§ 427.) An abundant effusion of liquor sangui- 
nis, of coagulable lymph and serum, of pus, or of inflammatory 
mucus, usually lowers the inflammation — that is, reduces the de- 
termination of blood, and may diminish the obstruction, but often 
does not remove it; and the effused matter may cause sundry 
mischievous effects, by compressing, stuffing, or obstructing the 
several structures in which it accumulates. We may with advan- 
tage pursue the history of effusions, by tracing their changes in 
the chief elementary tissues. 

Serous membranes, being simple in structure, give us the best 
illustration of the history of inflammatory effusion. In acute 
inflammation in a healthy subject, besides serum, an exudation 
of fibrin or coagulable lymph takes place in a few hours. This 
fibrin is at first in a semifluid, ductile state; so that the motion or 
pressure of the inflamed surfaces draws it into bands or threads, 
or spreads it into films, as we see it on the pleura, pericardium, 
and peritoneum. But if we examine inflamed surfaces which are 
less exposed to motion or pressure, as the looser parts of the 
auricles of the heart, the serous covering of interlobar divisions 



INFLAMMATION RESULTS EFFUSION. 233 

of the lungs, that of the less projecting parts of the intestines, and 
of the convolutions of the brain, we find the deposit of lymph 
not uniform in a film, but in points forming a granular surface; 
which shows that either more is effused at some points than at 
others, or that the concretion of fibrin having begun in points, 
chiefly augments around the same points. The granules thus 
deposited vary in size, from that of a grain of sand to that of a 
millet-seed; but if the deposit increases, they enlarge into patches, 
which may run into one another, often forming a mammillated 
coating of lymph. Even on surfaces which are subjected to mo- 
tion, the prevalence of the fibrinous effusion at points is shown 
by a villous or shaggy appearance of the lymph, from this, in its 
ductile state, being drawn into threads projecting from the points 
where it has first concreted: this is sometimes well seen in the 
pericardium. In the pleura, these inequalities are more oblite- 
rated by the rubbing motion of respiration, or by the pressure of 
liquid effusion. 

450. The lymph thus effused is (like the buffy coat of inflamed 
blood) at first transparent; afterwards it becomes yellowish, and 
more or less opaque, but in inflammation of a healthy subject 
generally retains some degree of translucency. In this respect, it 
contrasts with the product of inflammation in unhealthy subjects, 
purulent and tuberculous lymph, which is more opaque. But the 
most important character of healthy lymph is its high suscepti- 
bility of organization, which character I will in future designate 
by the term euplastic, (§211.) Euplastic lymph consists of fibrils 
of fibrin crossing each other in various ways, and mixed with nu- 
merous exudation corpuscles, both compound (cells with nuclei 
and granules) and simple, (granules and molecules.) Now, these 
are also found in the buffy coat of inflamed blood, (§ 212;) and 
there can, therefore, be no doubt of their identity, and that the 
blood thus altered by the inflammatory process is their source, 
(§ 438.) This leads us to anticipate what is the fact, that the 
plasticity of lymph will depend much on the good quality of the 
blood, as well as on the energy of the inflammation. Healthy 
blood, which abounds in red particles as well as in fibrin, fur- 
nishes the most plastic kind of lymph, (§ 183;) and inflammation, 
attended with the most active determination of blood, (so long as 
the integrity of the vessels is preserved,) separates this lymph in 
the greatest abundance. This lymph already possesses living 
properties, for its materials arrange themselves into the basis of a 
texture; but to sustain the life of this texture, it must be supplied 
with blood, and this takes place in the wonderful process of the 
formation of blood-vessels in it, which communicate with those 
of the adjoining parts. 

451. The precise manner in which vessels are formed in lymph 

20* 



234 PROXIMATE ELEMENTS OP DISEASE. 

is not distinctly ascertained. Mr. Kiernan observed inflamed 
capillaries become varicose, and at points project in pouches and 
diverticula, and stretch into loops. If these gave way, the blood 
would be injected into the lymph; and if something of channels 
were previously formed by the arrangement of the fibrils, or the 
elongation and communication of cells, it is cmite conceivable that 
a current would be effected by the vis a tergo through several 
openings, and that a return of the blood would take place by a 
reversal of the weaker currents. But the actual observation of 
the mode in which new vessels are formed is yet wanting. It 
has been ascertained by Schrceder, Liston, and others, that the 
new vascular channels are at first much larger than the vessels 
which supply them; they are afterwards contracted by the forma- 
tion of a basement membrane lined with epithelium; and the 
whole texture becomes more consistent and less bulky, exhibiting 
a filamentous and cellular structure, with nucleated cells scat- 
tered through it. This new membrane forms patches on, or ad- 
hesions between, the serous coverings of the lungs, the heart, and 
intestines; and provided these false membranes are loose, and of 
moderate thickness, they may cause no disorder. 

452. When the inflammation is of a low character, or when 
the blood is poor in red particles, and especially when these two 
conditions are combined, the solid products of inflammation are 
less capable of organization, and therefore may be called caco- 
plastic. As the process of organization varies in degree, so these 
products may attain to different degrees of structure, forming 
membranes of a denser, less pliant texture, and less vascular 
than the serous membranes to which they are attached, and 
which they therefore shackle. Thus patches of a kind of fibro- 
cellular or fibro-cartilaginous membrane are formed on the lungs, 
the heart, and the intestines; sometimes with the effect of mate- 
rially impeding the functions of these several organs. Where 
the effusion of lymph is scanty and slow, its granular mode of 
deposit is more obvious than in the more acute disease; for 
being less ductile, it is less readily spread or stretched by the 
motion of the parts, (§449.) This is well seen in chronic in- 
flammations of the peritoneum and arachnoid, in which the 
deposit is almost entirely in granules or flattened patches, com- 
monly called tubercles. These are generally of a buff or skin 
colour, of firm consistence, and sometimes exhibit slight traces 
of blood-vessels in them;* but sometimes their colour is more 

• Mr. J. Dalrymple has observed, that the vascularity of lymph may be seen 
earlier, in cachectic and scorbutic subjects, than in healthy lymph. But syphilis 
and scurvy may moderate inflammation, without rendering the lymph aplastic: 
the great impediments to organization of lymph are, its bad quality and exces- 
sive quantity, and the persistence of inflammation. In a scorbutic subject, Mr. 



INFLAMMATION EFFUSIONS, PLASTIC AND CACOPLASTIC. 235 

yellow and opaque, their texture uniform and tough, and they 
are totally destitute of vascularity. These constitute the forma- 
tions described under the names cirrhosis and crude yellow 
tubercle, and are the lowest of the organized products. Being, 
in organization and consistency, dissimilar to the membranes 
on which they are formed, they prove a source of irritation and 
constriction; and being liable to ulterior changes, (shrinking and 
contraction in the case of cirrhosis; further degeneration and 
softening in the case of yellow tubercle,) they may bring further 
mischief in contiguous parts. 

453. In some cases, again, more or less of the product of 
inflammation is aplastic, or totally incapable of organization, 
and is thrown off with the liquid in separate large globules filled 
with granules and molecules, constituting pus; or in detached 
flakes or curds, consisting of aggregations of irregular opaque 
corpuscles and molecules held together by a few fragments of 
fibrils: such effusions are exemplified in the sero-purulent liquid 
and curdy matter of low pleurisy, pericarditis, and peritonitis. 
It is obvious that such lifeless products must act prejudicially on 
the containing structures; and the fact might be anticipated that 
they are little susceptible of absorption. 

454. I have mentioned (§ 452) a low form of inflammation, 
and an unhealthy condition of the blood, as causing the caco- 
plastic character of the products of inflammation. It may be 
added, that the long continuance of any inflammation, and its 
occurrence in subjects in whose blood fibrin abounds, while the 
red particles are scanty, (§ 185, 195,) will pretty surely render 
the products cacoplastic or aplastic. At the onset of inflamma- 
tion, its products may be plastic, and the process of vascular 
organization (§451) may commence; but if the inflammation 
continues, its product either is thrown beyond the reach of vas- 
cular communication, or displaces that already effused, and thus 
the outer layer will be in a degenerating condition. Added to 
this, the pressure of the liquid effusion may impede the construc- 
tion and injection of the new membrane, which therefore is 
degraded into one of the cacoplastic or aplastic matters above 
described. Again in scrofulous or cachectic subjects, the blood, 
although scanty in red particles, abounds in fibrin, and this is 
readily effused in inflammation; but it is of low vitality, and 
susceptible of little or no organization."* There is yet another 

D. has shown, that even a large coagulum of blood may soon become vascular; 
but it docs not follow that either this or lymph in such subjects can be formed 
into real texture. 

* When a coagulum of fibrin is retained long in a vessel without becoming 
organized, it loses its structure, and softens into an opaque semifluid matter, 
which long was mistaken for pus; but Mr. Gulliver has shown that it consists of 



236 PROXIMATE ELEMENTS OF DISEASE. 

circumstance tending to lower the plasticity of lymph, although, 
from the observation of Mr. Dalrymple, it sometimes accelerates 
its organization* — that is, the admixture of the colouring matter 
of the blood with it. Laennec supposed that contraction of the 
chest had its origin in hemorrhagic pleurisy only. This is not 
correct; but I have many times remarked after death, that lymph 
on the pleura and pericardium, in chachectic subjects, is much 
stained with blood; and where patients with similar symptoms 
have recovered from inflammation, they have been affected with 
structural disease. So far as we yet know, the colouring matter 
does not form a material for organization; and, further, it is very 
probable that in such cases the colouring matter is itself diseased, 
(§186.) 

455. The more complex structure and secreting properties of 
mucous membranes considerably modify the form and appearance 
of the products of their inflammation. But, according to Gerber, 
Henle, and Gruby, they microscopically consist of exudation 
corpuscles, granules, and molecules, together with more or less 
amorphous and glutinous mucus, the natural secretion, and scales 
of epithelium. I must add, however, that, in the early stage, 
serum is present, manifest by the saline taste and coagulability by 
heat; and at an advanced stage, the mucus contains fatty matter. 

Irritation of mucous membranes merely causes a flux, (§ 379;) 
that is, the natural mucous secretion more copious, watery, and 
saline than usual, and containing fewer globules. But if the 
irritation be continued, and inflammation follows, the secretion is 
at first diminished by the effusion of serum and exudation cor- 
puscles into the interstices of the mucous and submucous texture, 
which causes more or less thickening or swelling. Soon, how- 
ever, the effusion overflows to the surface in the form of a more 
or less viscid, saline-tasted liquid, containing more globules and 
epithelium scales;! and as the inflammation becomes more in- 
tense, the globules predominate, and the mucus becomes more 
scanty, but is still very viscid. On the first decline of the inflam- 
mation, the mucous and saline matter diminish, and the globules 
compose the chief mass of the secretion, and give it the yellowish 
or greenish opacity seen in "concocted" sputa; and this opaque 
matter is afterwards gradually replaced by the natural mucous 
secretion. In some cases, especially in young subjects and others 

much smaller particles, mere irregular granules. In this state it bears the 
closest general and microscopical, resemblance to mature and softened tubercu- 
lous matter. It appears to me, that certain softened tuberculous appearances, 
met with in the lymph of serous membranes and parenchymata, are similar in 
their nature. 

* Medico-Chirurg. Trans., 1840, p. 212. 

f Gruby; Morphology of the Pathological Fluids. Translated by Dr. Good- 
fellow. (Microscopical Journal, Nos. 19 — 23.) 



INFLAMMATIONS RESULTS EFFUSIONS MUCOUS. 237 

in whom the inflammation penetrates to the submucous cellular 
texture, fibrinous matter is thrown out, forming films or shreds 
of lymph; but this very rarely becomes organized on mucous 
membranes, because their secreting apparatus and its product lie 
between the lymph effused and the vascular structure. Hence 
the exudation corpuscles of inflammatory mucus are degenerating 
or aplastic, and constitute the opacity of viscid, mucous, muco- 
purulent, purulent, and shreddy fibrinous matters exuded by in- 
flamed mucous membrane. If inflammation persists in a mucous 
membrane, the globules continue to abound in the effusion, com- 
monly rendering it opaque and purulent; and the natural mucous 
secretion being impaired, the product is more diffluent. But in- 
flammation rarely continues long over a great extent of surface; 
it is confined to patches, which yield their opaque effusion whilst 
other parts may be secreting natural mucus. Hence the com- 
pound appearance of the secretions in chronic inflammations of 
mucous membranes, (bronchitis, mucous enteritis, and cystitis.) 

Sometimes interstitial effusion, which takes place at the com- 
mencement of inflammation of mucous membrane, is not entirely 
removed by the subsequent discharge. In such cases there may 
remain a permanent thickening of the mucous and submucous 
texture, which is the cause of the indurations and strictures which 
inflammation sometimes leaves in the intestines and urethra; and 
to a less degree in the air-passages. This, however, it must be 
observed, is the result of inflammation rather of the submucous 
cellular texture than of the mucous membrane itself. 

45G. Inflammation of the skin presents great varieties as to 
the amount and kind of its products. The full consideration of 
these would lead us into the pathology of skin diseases, a subject 
replete with interest and practical importance, although sadly ne- 
glected amidst the artificial distinctions of writers on cutaneous 
diseases; but the subject is too wide to be discussed here. 

Some of the effusions in and from the skin have been glanced 
at under the head of the symptoms of inflammation, (§ 432.) It 
may now be added, that these effusions may consist of clear 
serum, with few exudation corpuscles and molecules, as in the 
liquid of blisters and blebs, and eczema, which dry into thin scabs; 
or of milky scrum more abounding in the corpuscles, which dry 
into thicker scabs, as in herpes, rupia simplex, &c; or of liquor 
Bangumis and purulent serum, with more numerous corpuscles, 
which form very thick, yellow, or brown scabs, as in rupia pro- 
minens, impetigo, and ecthyma; or the effusions may be chiefly 
solid, and into the substance of the dermis, as in tubercular in- 
lla nnnat ions and incipienl pustules. In all cases of inflammation 
of the skin, there is an Increased production of epidermis, which 
is sometimes thrown off in scales with the scabs; or in a peeling 



238 PROXIMATE ELEMENTS OF DISEASE. 

of the cuticle; or thickens, and forms a hard covering, liable to 
clefts and sore ulcerations, as in psoriasis, inveterate eczema, &c. 

457. Inflammatory effusion into the cellular texture consists 
of serum, with more or less of the exudation corpuscles and fibrin. 
In diffuse erysipelas or cellulitis, the fibrin is deficient, and the 
corpuscles either are in moderate numbers, or else are degene- 
rative, (purulent.) In phlegmonous inflammatian there is more 
fibrin, which circumscribes the effusion, and causes a harder 
swelling; and the pressure of this with a continuance of inflam- 
mation may lead to suppuration or sloughing. 

458. Effusions from inflammation of parenchymatous organs 
resemble those from inflammation of cellular texture; but the- 
parenchymata in general being very vascular, as well as yielding, 
the solid effusion may be very copious, without causing the pres- 
sure or tension that leads to suppuration and gangrene. The 
lymph effused exhibits, in regard to plasticity, the same varieties 
which we have described in the products of serous membranes, 
(§ 450, et seq.) But inasmuch as lymph effused in the paren- 
chyma of an organ would greatly interfere with its function, we 
rarely find it to become organized, except in limited portions, 
which thus remains solid and dense. More usually the matter 
deposited is gradually removed by absorption or secretion after 
the inflammation declines, or if the inflammation continues, the 
exudation globules and lymph are converted into, or replaced by 
pus or tuberculous matter — that is, degenerated corpuscles. 

459. Effusion so closely attends the process of inflammation, 
that the symptoms of effusion have been comprehended in those 
of inflammation. Swelling, pressure, obstruction, irritation, con- 
solidation, displacement, and various functional, as well as struc- 
tural disorders, may arise from the presence of effused matter. 
Hence the occurrence of effusion may aggregate some of the 
symptoms of inflammation, whilst others may be more or less 
relieved by it. Where a copious effusion takes place, the pain, 
heat, redness, and fever, are commonly reduced; for the vascular 
and nervous excitement and determination of blood are lessened; 
but the local or visceral disorder may be increased. The pulse 
may be as frequent, but it is less hard and full; the fever less con- 
stant, but it may continue in a lower degree, or assume a remit- 
tent or hectic form. The relief by effusion is greatest in slight 
inflammations, or where the effused matter can be thrown off 
from the body, as in the case of mucous membranes; but there 
may be much irritation and exhaustion of strength in the process 
of throwing it off, (as in cough and expectoration, diarrhoea, puru- 
lent micturition, &c.;) and these will be more harassing where, as 



INFLAMMATION — SUPPURATION AND ULCERATION. 239 

we have found is sometimes the case, the effusion does not remove 
the inflammation. 

Suppuration and Ulceration. 

460. The formation of pus among the products of inflamma- 
tion has been several times noticed, (§ 424, 453, 455, 457, 458.) 
Pus is an opaque, greenish, or yellowish white liquid, of creamy 
consistence, little odour, specific gravity varying from 1030 to 
1040. It is chemically composed of water, albumen or fibrin of 
the globules, (pyine,) albumen in solution, fat, osmazome, and the 
same saline matters as those in the blood. According to Gerber, 
mature pus contains more fat and less albumen than that recently 
formed. 

Microscopically, pus consists of serum, and globules of pretty 
regular size and form. These globules are obviously a modifi- 
cation of the exudation corpuscles; each consists of a fluid, with 
granules and molecules contained within a thin cell, which some- 
times has granules also on its surface. The granules render the 
appearance of the investing cyst or cell obscure; but its existence 
is clear from the action of distilled water, which causes the cell 
to dilate (by endosmosis) to double its former size;* and what is 
curious, the continued granules swell also, which shows their 
vesicular nature. Pus globules are larger than the general size 
of exudation corpuscles, (§ 424,) and exceed in size the blood 
discs, (Gulliver.) According to Mr. Addison, they measure from 
W?re t0 tsW °f an inch. Besides in size, they differ from other 
exudation corpuscles in being more distinctly vesicular, and con- 
taining a fluid, as well as granules: their more readily swelling, 
bursting, and shedding their contents under the influence of water 
or solution of potass, (Addison,) may be referred to the same 
difference. This probably imitates the process by which the exu- 
dation corpuscle is converted into a pus globule. From a pecu- 
liar constitution cither of the corpuscles or of the adjoining fluids, 
the disposition to endosmosis is increased, and the corpuscles, 
and even their contained nuclei, swell into vesicles, instead of 
remaining in the gelatinous condition which characterizes the cor- 
puscles within the blood-vessels, (§ 416,) and in coagulabie lymph, 
(§ 424.)} 

• Gulliver; Notes to Gerber, PI. 259, 60. Gerber describes pus globules as 
flattened discs, consisting of seven granules, without an investing cell, and 
formed by a partition of the exudation corpuscle into these granules. This state- 
ment is not confirmed byGrubyor Addison, whose descriptions more correspond 
With those of Mr. Gulliver, and with observations which my friend Mr.Dalrymple 
has described to me. 

■j- Pus is not produced in birds or in cold-blooded animals; the reason of this 
is not understood, aa the exudation corpuscles do not materially differ from those 



240 PROXIMATE ELEMENTS OF DISEASE. 

461. Another distinguishing character of the pus globules is 
their want of cohesion; and in proportion as they predominate, 
they impair the consistence of fibrin or mucus with which they 
may be combined. Pus effused into cellular and complex tex- 
tures also impairs their cohesion, and leads to the destruction of 
their substance; hence suppuration consists in not only the form- 
ation of pus, but also its substitution for more or less of the in- 
flamed texture: for this reason suppuration, more than effusion, 
may be called a termination of inflammation, for the inflamed 
vessels are in great part destroyed. 

462. The circumstances which determine suppuration as a re- 
sult of inflammation, are chiefly three: — 1. A certain intensity 
(obstruction and determination in the vessels, § 419,) and duration 
of the inflammation; 2. The access of air to the part; 3. A pecu- 
liar condition of the blood. 

1. Intensity and continuance of inflammation pretty surely 
lead to suppuration in common inflammation of the true skin, cel- 
lular textures, glands, and most parenchymatous organs. Lymph 
is effused first, and it is pretty certain that the exudation corpus- 
cles, at least, of this lymph, are changed into pus globules by the 
continued operation of the distended vessels. In circumscribed 
external inflammations, pressure, which reduces the distension, 
sometimes prevents suppuration; and in serous membranes, in- 
tensity and continuance of inflammation do not lead to suppura- 
tion, because the distended vessels are fewer and smaller, and in 
less close contact with the exudation corpuscles. In mucous 
membranes, duration, rather than mere intensity of inflamma- 
tion, causes the more abundant formation of pus; but the dispo- 
sition of mucous membranes to secrete pus rather than lymph 
may depend on the disintegrating effect of the remaining mucous 
secretion. 

2. The access of air to a wound or to a serous membrane dis- 
tinctly promotes the formation of pus, probably by a chemical 
influence, which disposes the exudation corpuscle to swell into a 
vesicle; but it is uncertain how much this influence may be due 
to a chemical change, and how much to the increased irritation 
which the contact of air may cause on living parts. Certainly a 
limited access of air promotes the decomposition of pus, and 
leads to serious consequences from its putrefactive changes. 

3. The condition of the blood which promotesthe suppurative 
termination of inflammation is not well understood. It is gene- 
rally connected with a cachectic, ill-nourished state of the sys- 
tem, as exemplified in persons affected with impetigo and other 

of mammalia. A careful investigation of the products of inflammation in birds, 
as well as in animals, would probably throw much light on the true nature of 
pus and lymph. 



INFLAMMATION RESULTS SUPPURATION. 241 

suppurating diseases of the surface, in whom slight scratches or 
punctures readily fester, and whose wounds do not heal by the 
first intention, (simple plastic adhesion.) It has been said that, in 
such cases, pus globules may be found in the blood. It is quite 
certain, however, that the presence of pus in the body, when that 
is not duly limited or thrown off, causes a tendency to the pro- 
duction of more; and the most plausible notion with regard to 
this is, that it operates somewhat in the manner of a leaven, like 
other morbid poisons, (§ 98.) For a similar reason, suppuration, 
when begun in a part, usually proceeds until pus is substituted 
for the inflamed textures and former products of the inflamma- 
tion; and until by the process spreading, the pus finds exit on 
some surface. 

463. The process of suppuration strongly illustrates the oppo- 
site character of the elements of inflammation before alluded to, 
(§ 421.) The obstruction to the passage of the blood through 
many vessels of an inflamed part, and the increase of this ob- 
struction by the pressure of matter effused by those vessels that 
are the seat of determination, reduce the vitality of the obstructed 
parts to so low a degree, that they are unable to withstand the 
chemical solvent power of the effused fluids,* exalted as it is by 
high temperature. The textures are therefore gradually dis- 
solved,! and are absorbed away, whilst the exudation globules 
in form of pus occupy their place, and continue to be effused by 
the vessels which are still the seat of determination of blood. 
This assumes that absorption is still active in an inflamed part; 
and the assumption is warranted by the fact, that the absorbing 
vessels, veins and lacteals, remain perfectly free: and the very 
occurrence of increased pulsation and flow in communicating 
and contiguous vessels, (§ 413,) will promote the exosmosis of 
fluid matter by the absorbent vessels. That the pus globules 
should remain unabsorbed will not appear extraordinary, when 
their large size is taken into account, (§ 460,) and that they are 
not dissolved by their proper fluid. Thus the combination of 
apparently opposite results, which has been considered so inex- 
plicable, — excited and lowered action, increased secretion and 
increased absorption, — admits of an explanation in exact accord- 
ance with all the phenomena. 

464. The amount and extent of the process of suppuration 

• That the liquid of pus can chemically dissolve dead animal matter was 
proved by J. Hunter, who found that pieces of raw meat were dissolved in ab- 
scesses, or even in pus kept warm out of the body. The experiments of Sir C. 
"Wintrin^harn show that other animal fluids have a like property. Dr. Prout 
notices similar facts. 

f The idea that the removal of textures in suppuration is owing to their death, 
originated with Dr. Billing. (See his "Principles of Medicine.") 
21 



242 PROXIMATE ELEMENTS OF DISEASE. 

varies in different cases. In some cellular and parenchymatous 
textures it sometimes occurs a.spurule?it infiltration, not circum- 
scribed by lymph, but leaving the texture much softened, and 
partially removed. This diffused kind of suppuration is to be re- 
ferred either to the porous nature of the organ (as with the lungs) 
not admitting an effusion of lymph sufficient to limit the suppu- 
ration, or to a purulent diathesis or disposition in the blood, 
(§ 462.) In most cases, the process of suppuration is limited 
around by solid effusion, which may be either the remains of the 
earlier product of the inflammation, or it may be thrown out ex- 
pressly for the purpose of defending the adjoining structure from 
the operation of the pus, which is obviously a noxious matter. A 
collection of pus thus circumscribed is called an abscess; and 
when mature, it represents the perfection of suppuration. The 
blood-vessels of the inflamed part are destroyed like other tex- 
tures; but their supplying trunks are obstructed by lymph; whilst 
the adjoining capillaries, which remain pervious, become dilated 
and varicose on the walls of the abscess, which are lined with a 
coating of organized lymph, the vessels in which continue to se- 
crete pus; whence this lining is called the pyogenic membrane. 
As the pus increases, the abscess becomes enlarged, generally 
towards some cutaneous or mucous surface where it points; the 
, skin or membrane ulcerates, and the pus is discharged. The 
direction which the abscess takes seems to be that in which there 
is least resistance: the parts here are more stretched than others; 
and from being stretched, their vessels are more obstructed, so 
that they cannot maintain the vitality, nor throw out the same 
amount of protecting lymph, which limits the abscess in other 
directions. Fibrous and other hard textures resist the progress of 
abscesses and the escape of pus. Serous membranes, by their 
ready plastic process, first adhere together, and then often give 
passage to the contents of an abscess through them, without any 
pus escaping into their sac. Thus abscesses of the liver and kid- 
ney make their way across the peritoneum into the intestines, 
through the walls of the abdomen, and even through the dia- 
phragm, pleura, and lungs. Where pus from an abscess does 
make its way into a serous sac, it causes severe irritation, and 
fatal inflammation. 

465. After an abscess has opened, it may continue to discharge 
pus, pure or diluted with serum or sanies; but in healthy subjects, 
a process of healing takes place by an increased effusion of lymph, 
and growth of new vessels in it in the form of granulations, 
throughout the interior of the abscess. Pus is still formed by the 
superficial layer of exudation corpuscles degenerating or swelling; 
and a free vent must be given to this pus until the growth of the 
granulations and the contraction of the walls shall have obliterated 



INFLAMMATION RESULTS ULCERATION. 243 

the cavity of the abscess, and left no more room for the pus to 
accumulate. 

466. Ulcers sometimes arise from abscesses: an abscess that 
has discharged its contents is, in fact, an ulcer. But more com- 
monly, ulcers originate from limited inflammations of the skin or 
mucous membranes, in which the natural cohesion of the skin is 
so much impaired, that it is broken up at one or more spots, and 
either carried away in the pus discharged, or absorbed. There 
is then left a solution of continuity or excavation, the bottom and 
edges of which continue to discharge pus, or a serous fluid mixed 
with exudation corpuscles, and sometimes blood particles. Ulcers 
may tend to spread by the same process; or to heal, by the effu- 
sion of fibrin on their walls and the extension of vessels into this 
lymph in the form of granulations, which are the' materials of the 
new texture. Ulcers, besides, present a great diversity of cha- 
racter in the nature of their secretion, and the condition of their 
walls, as well as in the symptoms which they produce: these 
circumstances constitute the varieties of ulcers described in surgi- 
cal works. 

The cause of ulceration is commonly local, the inflammation 
interfering with the normal nutrition of a part. It is often pre- 
ceded by induration from the amount of solid deposit; and the 
ulceration commences in the centre of the induration, because the 
nutrient influence of the vessels is most reduced by the pressure 
at that spot. But a very poor condition of the blood is often 
much concerned in determining this result, and seems to be some- 
times sufficient to cause ulceration without any distinct previous 
induration, or even inflammation; the parts that suffer being 
either those which have become congested by posture, (as in 
cachectic ulcerations of the legs,) or those most remote from the 
nourishing influence of the blood; such as the non-vascular 
textures, the cornea, cellular parts of cartilages, &c. In cases of 
extreme anaemia, (§ 268,) where the fibrin and albumen of the 
blood arc very defective, (§ 197,) ulcers of this description arise, 
and are to be counteracted by measures the very opposite to 
antiphlogistic. A similar result was found, by Majendie, to ensue 
in animals fed on sugar, starch, and other non-azotized articles of 
food. 

467. Softening of textures may arise from the same change 
which, in a greater degree, and more circumscribed form, causes 
ulceration, li has already been noticed as an effect of inflam- 
mation, (§ 127:) and it may now be added, that the condition of 
the blood which disposes to ulceration sometimes leads to the 
more diffused operation of the same change in the softening of 
textures. Thus softening of the brain, Liver,muscle, and mucous 
membrane, sometimes results from anaemia, or imperfect supply 
of blood in these parts. 



244 PROXIMATE ELEMENTS OF DISEASE. 

468. It may be gathered from the previous description, that 
suppuration is a work of destruction, and therefore is, in some 
measure, to be contrasted with effusion of lymph, which is in- 
tended to be a process of construction or reparation. Pus is 
totally aplastic itself; it is formed at the expense of the plastic 
product of the vessels, and the liquid of pus seems to act as a sol- 
vent or septic on textures when their vitality is reduced. Although, 
therefore, suppuration is often useful in terminating inflammation, 
and in removing superfluous products and parts injured by it or 
its causes, yet suppuration must be viewed as a depressing and 
exhausting process, and its product as having a noxious charac- 
ter: the symptoms which accompany it will be found to corre- 
spond with this view. 

469. The occurrence of suppuration is marked by a diminution 
of the heat, pain, and other signs of irritation and increased action 
in the part. The pain often becomes throbbing, as if the external 
pressure on some of the larger vessels had yielded, and these be- 
come expanded at each pulse. The swelling becomes softer; and 
if within the reach of touch, is felt to be first more yielding under 
the finger, and afterwards to present the fluctuation of fluid mat- 
ter. The redness present in inflammation is also diminished, 
being wholly superseded by the pale yellow of purulent effusion 
in the central parts of the suppurating mass, being mottled by it 
in others, and retaining its deep character only in those parts of 
the circumference where the suppuration has not reached. In 
external inflammations, the redness of the skin becomes deeper 
before suppuration; but when this process reaches the skin, a pale 
spot is seen, which by its fluctuating feel indicates the approach 
of the abscess to the surface. 

The great reason of the alleviation of the symptoms of inflam- 
mation, on the occurrence of suppuration, is the diminution of 
tension and hard swelling, which chiefly cause the pain and irri- 
tation, (§ 433,) and where suppuration takes place amidst un- 
yielding parts, as under a fascia or within a bone, the tension is 
increased rather than lessened, and the symptoms of pain and 
irritation may be more severe than ever. The powerful influence 
of hydraulic pressure in causing the injection of a liquid into a 
compact texture, and the swelling of the pus globules by endos- 
mosis after their first formation, will assist in explaining the effu- 
sion of pus under a dense periosteum or theca, and the extreme 
pain and irritation which it produces. The free secretion of pus 
from mucous membranes relieves inflammation, and removes the 
submucous deposit, (§ 455.) 

470. The influence of suppuration on the system is manifest 
in the lowering of the inflammatory fever; the pulse losing its 
strength, but retaining its frequency; the heat subsiding or alter- 



INFLAMMATION RESULTS SUPPURATION SYMPTOMS. 245 

sating with chills and sweats; the general redness being succeeded 
by paleness, or a hectic flush; the urine depositing a pale or pink- 
ish sediment; and the general excitement giving place to weak- 
ness and exhaustion. The amount of the change will greatly 
depend on the extent of the suppuration, and the importance of 
the organ affected; but another chief circumstance determining 
the effect of suppuration, and proving the noxious influence of 
pus on the system, is the difference between those suppurations 
that are diffused without a circumscribing barrier of lymph, and 
those that are thus limited, or are thrown off at once from the body. 
In some cases of inflammation of the cellular texture, skin, and 
of serous membranes, pus is formed with little or no previous 
exudation of lymph, and produces in the system the most for- 
midable effects. The pulse becomes very frequent and weak; 
the tongue brown and dry, or coated with an offensive fur, and 
tremulous; sweats break out profusely; the urine is scanty, high- 
coloured, and offensive, sometimes suppressed; diarrhoea some- 
times occius; hiccup comes on; the mind is much depressed, or 
excited by occasional delirium; the patient's manner and motions 
are agitated and restless; the breathing becomes hurried and sigh- 
ing; and death ensues in from one to four days from the com- 
mencement of these symptoms. Similar results ensue in suppu- 
rative inflammation of veins; and they have been known to follow 
where an external abscess has suddenly subsided without open- 
ing, and in cases in which the discharge from a large suppurating 
wound has suddenly ceased. On opening the body after death, 
in a ihw such cases, nothing peculiar lias been found, except a 
general fluidity of the blood, and the gravitative congestions and 
stains which that fluidity induces, (§ 196.) In most instances, 
however, there are found in some of the viscera, particularly the 
lungs and liver, purulent deposits, as they are called; collections 
of pus, generally confined to lobules or portions of lobes of these 
i, with more or less inflammatory injection and deposition 
of lymph around the collections. In these cases, there can be 
little doubt that pus in some way is conveyed in the circulation; 
and being arrested in the lungs and liver, leads to the formation 
of more, (§ 462,) — whether by the production of suppurative 
phlebitis, as supposed by Cruveilhier, Dance, and others, is 
doubtful, — and that the pus in the blood is the cause of the for- 
midable symptoms and results above noticed. From the experi- 
ments of M. U'Arcet,* it is probable that the poisonous influence 
of purulent matter arises from chemical changes induced by air 
in its si rosity, (§ 450;) but that obstruction to the circulation in 

• " Recherches sur les Absc6s Multiples," &c; and " Brit, and For. Med. Rev. 
Jan. 1848." 

21* 



246 PROXIMATE ELEMENTS OP DISEASE. 

the lungs and liver, and consequent circumscribed inflammations 
of these organs, result from cohesion and consolidation of the 
globules of pus contained in the blood. 

Some difficulty presents itself as to the possibility of the glo- 
bules of pus being absorbed, their large size apparently exclud- 
ing them from passing through the coats of the vessels, (§ 463;) 
and it is more probable that, in the cases under consideration, pus 
is generated within as well as without the blood-vessels, just as 
we have found (§ 416) the exudation corpuscles to be, of which, 
in fact, the pus globule appears to be a modification, (§ 460.) In 
fact, Mr. Gulliver distinctly describes pus globules, with all their 
peculiarities of size and constitution, (§460,) as present in the 
blood of persons affected with severe inflammation and suppura- 
tion; and if these observations are exact, (as from the known ac- 
curacy of their author there is every reason to believe they are,) 
the varied symptoms occurring in different cases of suppuration 
may be fairly referred to the different amount to which the pus 
globules are produced within the vessels, and, perhaps, to putre- 
factive changes which they subsequently undergo. 

471. The preceding observations prepare us for the fact that, 
besides the extreme effects above noticed, extensive local suppu- 
rations cause various symptoms of depression or low irritation. Of 
this kind are the rigors often experienced at the commencement 
or increase of suppuration. Dr. Billing plausibly ascribes this to 
the system sympathizing at the death of the part which is under 
destruction by the suppurating process; but the rigor not being 
always present suggests rather that the presence of a certain 
amount of pus in the blood might be its cause. 

Again, when suppuration continues long, even if it be dis- 
charged outwardly, as in extensive wounds, or ulcerations of the 
skin or mucous membranes, there is a great wasting of strength 
and flesh, with a partial febrile irritation of a peculiar kind, called 
hectic fever. This is remittent, in its symptoms, the exacerba- 
tions recurring once or twice daily, beginning with chills and de- 
pression, and followed by frequent pulse, partial heats, especially 
of the cheeks, hands, and feet, and ending in a profuse perspira- 
tion. As this proceeds, the body more or less rapidly wastes, 
and colliquative diarrhoea, vomiting, and aphthas of the mouth, 
often hasten the fatal result. The febrile part of hectic is most 
observed in the young and irritable; but the depressing and ex- 
hausting effect of extensive suppuration is seen in all cases, in 
progressive emaciation and cachexia. 

472. The matter of abscesses is laudable or healthy in pro- 
portion as it is thick and opaque, but uniformly liquid and free 
from smell; for although, even in this state, it is fit only to be 
expelled from the body and is prone to decomposition, yet the 



INFLAMMATION — RESULTS — GANGRENE. 247 

formation of such pus is pretty sure to be attended with a pro- 
tection of lymph, and it is far less noxious than ill-conditioned 
sanious matter, the fetor of which indicates that decomposition 
has already begun. 

Gangrene. 

473. Gangrene, like the more complete forms of suppuration, 
may well be called a termination of inflammation; for the in- 
flammation ends in the death of the part. In suppuration, the 
dying textures are softened and displaced by pus as fast as they 
die; in gangrene, the textures die more extensively than pus is 
formed, and they run into decomposition without being removed. 
In some cases, especially in limited gangrene, the dead portion is 
dissolved away at its circumference by the inflammatory exuda- 
tion from the living parts, and it is thus separated or sloughed 
from them; but if the dead portion be extensive, and the power 
of the living parts low, the separating process will not be accom- 
plished before decomposition ensues, which produces the changes 
called gangrene and sphacelus. 

474. The circumstances which cause inflammation to termi- 
nate in gangrene are those which completely suspend the circu- 
lation in the part, (§ 273,) and those which greatly injure the 
composition of the blood or directly destroy vital properties. 
The circulation in a part may be destroyed by long-continued 
pressure, by severe contusion, laceration, or other mechanical 
injury, by extreme heat or cold, by strong chemical agents, by 
the excessive pressure of the solid matter effused in the early 
stage of inflammation, (as in carbuncle,) and even by an extreme 
amount of congestion.* The occurrence of gangrene is favoured 
by extreme weakness of the heart, the great moving power of the 
circulation; and the failure is most manifest in parts most re- 
mote from the heart, as in various structural diseases of this 
organ, in low fevers, and states of extreme exhaustion. It is 
favoured by ossification or partial obstructions of the supplying 
arteries, which, although adequate to maintain the ordinary 
nutrition of the part, cannot dilate to supply the demand increased 
by any injury or irritation of the part. The agents, which cause 
gangrene, by a directly destructive operation on the vital proper- 
tiesofthe solids and fluids of the body, are various strong poisons, 
sucfa as arsenic, sulphuretted hydrogen, the poison of the rattle- 
snake and other venomous animals, the poison of the plague, 
malignant scarlatina, small-pox, and erysipelas, hospital gangrene, 
glanders, &.c. 

* Two cases of gangrene of the lung which have occurred in my practice 
seemed referable to this cause. 



24S PROXIMATE ELEMENTS OF DISEASE. 

475. An external part becoming gangrenous loses all feeling 
and other vital properties; its colour becomes livid, or leaden, 
greenish, or almost black, the cuticle rises in blisters on it, and 
begins to exhale an offensive odour. The rapidity of this change 
will depend much on the moisture and warmth derived from the 
adjoining living parts; in dry gangrene, the dead portion becom- 
ing horny and black instead of putrefying. For the converse 
reason, in internal parts the progress of decomposition is more 
rapid. The putrid matter affects the living body (like many 
animal poisons) as a local irritant, and a general sedative or de- 
pressing influence: and the symptoms will vary much as one or 
the other of these two operations predominates. 

In persons of robust constitution, active vascular system, 
(§ 112, 120,) and good blood, (§ 195,) a dead part arouses active 
inflammation and effusion of lymph in the surrounding living 
parts, which may protect the system more or less completely 
from the infection of the dead matter. In such cases, although 
gangrene be present, the predominant symptoms may be those 
of inflammation and inflammatory fever. But living parts, with 
all their activity, cannot long withstand the pernicious influence 
of dead matter; so that if this matter be not soon thrown oil' in 
the form of a slough, (§ 473,) or liquefied in the inflammatory 
exudations poured out, the system becomes infected, and sutlers 
from its poisoning and prostrating operation. This will happen 
more surely and early, where the dead part is in the interior of 
the body, of great extent, surrounded by vascular texture, and 
with its decomposition promoted by the warmth and moisture. 
In subjects of weak constitution, feeble vascular system, and 
blood defective in plastic matter, (§ 196,) the irritation of dead 
matter may fail to excite a protective (adhesive or plastic) in- 
flammation, and the putrid or typhoid symptoms then show 
themselves earlier, and prove more speedily fatal. These symp- 
toms are increasing feebleness and frequency of the pulse, reduc- 
tion of the fever, collapse and extreme pallidity of the countenance, 
cold sweats, brown, dry, or clammy foul tongue, low delirium, 
or restlessness and agitation of manner, hiccup, fetid diarrhoea, 
urine very offensive or suppressed, coma or syncope, and death. 
In external parts, or those which communicate with the surface, 
the putrid odour of the gangrenous part becomes a distinguishing 
physical sign; in gangrene of the lungs it is communicated to the 
expectoration and breath; in other cases, the whole body exhales 
a foetid odour. 

The supervention of gangrene sometimes terminates the pain 
and other severe symptoms of the preceding inflammation, and 
thus induces a false calm; but they are often replaced by distress- 
ing symptoms of nervous irritation, which subside only with the 
collapse of death. 



INFLAMMATION — STHENIC — ASTHENIC — ACUTE. 249 

476. Ill concluding this account of the results or terminations 
of inflammation, I must repeat what was said at the beginning, 
(§ 445,) that they rarely occur quite separately one from another, 
and in many instances they are all combined in different portions 
of an inflamed organ or texture. Thus resolution is always at- 
tended with some amount of effusion: lymph often has the colour, 
opacity, and much of the microscopic character of pus; suppura- 
tion is almost always preceded and generally accompanied by 
the efl'usion of some lymph; and often abscesses are attended 
with gangrene and sloughing of parts; and these combinations are 
further illustrated by the terms, purulent lymph, flaky pus, 
sloughing ulcer, gangrenous abscess, &c, which pathologists 
are obliged to employ to describe what they meet with. 

VARIETIES OP INFLAMMATION. 

Inflammation may vary in consequence of the predominance 
or defect of some of its elements or results, or from its combina- 
tion with some of the other elements of disease previously con- 
sidered. Or inflammation may derive a peculiar character from 
the nature of its exciting cause, which is exemplified in what are 
called specific inflammation. The following varieties demand a 
brief notice: — sthenic and asthenic; acute, subacute, and chro- 
nic; congestive; phlegmonous; erysipelatous; pellicular or 
diphtheritic; hemorrhagic; and scrofulous. Of the specific in- 
flammations, the gouty and rheumatic, syphilitic and gonor- 
rhceal, will be merely alluded to. 

477. The varieties of inflammation termed sthenic and asthenic 
correspond with the parallel varieties of plethora, (§ 279,) haemor- 
rhage, (§ 360,) and flux, (§ 393,) and are referable to a difference 
in the strength and irritability of the heart and arteries, (§ 110, 
120, &c.) Thus sthenic inflammation is marked by a strong 
hard pulse, high fever, (§ 442,) very fibrinous blood, (§ 20S, 438,) 
a full and active development of the chief symptoms of inflam- 
mation, (§ 429,) and a tendency generally to the more plastic 
products, (§ 450.) Patients affected with sthenic inflammation 
require and bear a greater amount of antiphlogistic treatment; 
and in thorn, if used in time, it is commonly most successful, for 
sthenic inflammation occurs in those of the most robust constitu- 
tion, in whom the effects of disease are most readily shaken off. 

Jlslhcnic inflammation occurs in persons the tone and real 
strength of whose vascular system is low, (§ 116, 123,) and their 
blood (generally speaking) poor, (§ 207.) The pulse isnot always 
affected; when it is affected, it is in frequency more than in 
strength or firmness; the fever, if there be any, is of a slight, re- 
mittent, OI low character, (§ 442, &C.) The products are either 



250 PROXIMATE ELEMENTS OF DISEASE. 

scanty, or of a cacoplastic or aplastic character, (§ 451;) or the 
effusion may be chiefly watery, the inflammation differing little 
from flux and dropsy. 

478. The terms acute, subacute, and chronic, applied to in- 
flammation, properly relate to its duration; but they are often 
used in the sense which I have given to sthenic and asthenic. 
Jicute inflammation may be, and commonly is, sthenic; but it is 
by no means always so: its distinctive character is, that it tends 
to a speedy termination of some kind or other. It may end in 
resolution, effusion, suppuration, or gangrene, in a period varying 
from a few days to three weeks. An inflammation lasting above 
the latter period is subacute, and if protracted beyond six weeks 
is properly called chronic. Very commonly, inflammation is 
acute because it is severe or sthenic, its intensity leading to a 
speedy result: but asthenic inflammation is often also short in its 
duration; whilst chronic inflammation sometimes presents a good 
deal of the sthenic character, (§ 477.) Acute inflammation, when 
at all extensive, is attended with considerable fever and constitu- 
tional disorder. With subacute inflammation the fever is less, 
and may even be absent. In chronic inflammation there is 
rarely fever; when present, it is of a remittent or hectic kind, 
(§ 444, 471.) 

The products of acute inflammation are commonly so copious 
as to be obvious in their character, being coagulable lymph, pus, 
inflammatory mucus, &c. In subacute inflammation they are 
often intermediate, such as purulent lymph, curdy matter, and 
tubercle in some of its forms. As with asthenic inflammation, 
the more they are in quantity the less likely are they to become 
organized. 

479. Chronic inflammation may originate in the acute or sub- 
acute forms, the vascular obstruction and excitement persisting in 
the part, even after some of the results (§ 445, formerly called 
terminations) of inflammation have been produced. Its general 
character is asthenic; but there may be considerable determination 
of blood and local excitement. Its effect in disturbing the func- 
tions, both of the part which is its seat, and of other parts, is much 
less prominent than that of acute inflammation; but its duration 
causes a more serious and lasting alteration of structure. The 
matter effused by serous membranes in chronic inflammation is 
always either cacoplastic or aplastic; hence, dense and contractile 
adhesions, or patches of fibrocellular or semicartilaginous matter, 
cirrhosis, gray miliary tubercle, curdy and yellow tuberculous 
matter, may be numbered among the common products of chronic 
mflammation. Mucous membranes discharge muco-purulent mat- 
ter, and the . more complex membranes of this class become 
thickened and may ulcerate. Sub-mucous textures become the 



INFLAMMATION VARIETIES — CHRONIC — CONGESTIVE. 251 

seat of deposit, which, in becoming organized, often contracts, 
forming strictures in mucous passages. These strictures, by 
obstructing the passages, may lead to dilatations above them. In 
glands and other complex textures chronic inflammation causes 
consolidation and induration, which often afterwards contracts 
and causes obliteration of the connected texture, as in the changes 
in the lungs, liver, and kidney, inaptly described under the name 
cirrhosis.* Sometimes the indurated parts, from the pressure on 
their vessels, become softened, (§ 463,) as in softening of the brain, 
or undergo a process of irregular suppuration and ulceration, as 
in the excavation of the lungs after chronic inflammation. As we 
noticed of congestion, (§ 311,) so it may be added of chronic in- 
flammation, that the hypertrophy or excessive deposit of nutritive 
material is irregular, more in some textures than in others, gene- 
rally abounding most in the interstitial cellular or filamentous 
tissue, which, by its hypertrophy, presses on the vessels and other 
textures, and often causes their atrophy and partial obliteration. 
Chronic inflammation in the cartilages ends in caries and ossifi- 
cation: in the bones also it causes caries or exostosis, just as in the 
skin and other compound textures it leads to induration as well as 
ulceration. The production of these apparently opposite results 
by tbe same process, inflammation, is not paradoxical, when we 
bear in mind the compound character of this process, and the 
variations arising from different proportions of its elements and 
products. Chronic inflammation exhibits these opposite results 
the more strikingly, because its effects are accumulated by its long 
duration; the hypertrophy arising from one of its elements (deter- 
mination of blood) increases in the immediate neighbourhood of 
atrophy and ulceration, the results of another of its elements, 
(vascular obstruction.) 

480. Congestive inflammation is that in which the accumula- 
tion and retardation of the blood in the vessels of the affected part 
predominate over the determination of blood. Hence it is com- 
monly asthenic in its character, (§ 477,) and generally originates 
from causes producing congestion in the first instance, (§ 403,) 
the reaction which converts this into inflammation being imper- 
fect or partial. Its symptoms are less prominent than those of 
more active inflammation, and partake more of the character of 
those of congestion. Thus there may be little pain, heat, fever, 

• Mr. Gulliver describes the consolidation of chronic pneumonia as charac- 
terized by " dark exudation corpuscles," as pale exudation corpuscles are the 
chief objects in red or acute hepatization. It appears, however, that these 
Corpuscles ate not dart from colour, but merely from opacity, as pus and tubercle 
an-; and they bear a further resemblance to this last product in their irregularity, 
in shape, ize, and composition, being of various shapes, and consisting ojf 
lies, generally without a nucleus, and often without envelop. — Notes to 
Dr. Boyd'fl " Vital Statistics," Edin. Med. and Sur. Jour.. July, 1843. 



252 PROXIMATE ELEMENTS OP DISEASE. 

and other signs of irritation or increased action; but the redness 
(where visible) is more marked and deeper than usual, and if 
the organ be very vascular, (as the liver, lungs, and kidneys,) 
the swelling may be considerable. Congestive inflammation is 
usually subacute or chronic, not tending to speedy results; but 
a kind of flux or dropsy may occur early, as from congestion. 
(§ 375.) So, too, the solid or nutritive effusion is generally 
cacoplastic, like that of congestion, (§ 311;) hence the consoli- 
dations or indurations arising from it are often of a dense or in- 
dolent kind, tending to contract, or to degenerate still further 
into aplastic matter, (tubercle.) The inflammation of the lung 
supervening on disease of the heart, on bronchitis, and asphyxia, 
is generally congestive; and so is inflammation of the liver from 
any cause. 

481. Phlegmonous inflammation is exemplified in the phleg- 
mon, furuncle, or boil of the integuments. Its chief character 
consists in its being abruptly circumscribed by an effusion of solid 
lymph, which brings the inflammation to a termination, either by 
suppuration, or by slow subsidence, as in the case of blind boils. 
A highly fibrinous condition of the blood (§ 195) contributes to 
render inflammation phlegmonous; but this form of inflammation 
is that commonly exhibited by cellular and parenchymatous 
textures. The type of phlegmonous inflammation is usually 
sthenic, (§ 477;) and even where it advances to suppuration or 
sloughing, it defends the body against the noxious influence of 
the pus and dead matter. Hence the fever is more inflamma- 
tory, (§ 442,) and the local pain, irritation ,and heat, are con- 
siderable. 

432. Ery thematic or erysipelatous inflammation is contrasted 
with phlegmonous, in its tendency to spread, not being attended 
with the effusion of much lymph. In its severe forms, it is 
accompanied by much redness, pain or smarting, heat, and swell- 
ing; the effusion is chiefly serous, and often raises the cuticle in 
blisters. In its worst kinds, it terminates in diffused suppuration, 
sloughing, or gangrene. The fever is also of a lower type (§ 443) 
than in phlegmonous inflammation; being attended by great 
weakness, disorder of the secretions, foulness or dryness of the 
tongue, with delirium, and confusion or dullness of the senses; 
and in the worst cases, the fever is typhoid, with stupor, mutter- 
ing delirium, dry brown tongue, sordes on the teeth and lips, 
slight convulsive startings of the limbs, (subsultus tendinum,) 
foetid or suppressed secretions, and sinking. 

These adynamic or typhoid symptoms show the presence of 
something more than a form of inflammation, and that something 
must be considered to be a poison. It is probable that this poison 
sometimes originates in infection, (§ 93;) for persons in the same 



INFLAMMATION VARIETIES PELLICULAR. 253 

room, or who have had much communication with a patient 
with erysipelas, have been more frequently attacked than others; 
but it is also pretty certain that bad ventilation, and a crowded 
imcleansed state of surgical patients, are capable at any time of 
rendering common inflammation erysipelatous; and this effect 
is much promoted by unknown epidemic conditions of the atmo- 
sphere, (§ 89.) The most probable hypothesis which we can form 
of this matter is, that under certain circumstances the products 
of inflammation become (as we know they sometimes do, § 470,) 
poisonous; and capable of acting (as many animal poisons do) as 
local irritants and general sedatives or depigments; that they then 
modify the character of the inflammation, and depress the whole 
vital powers, (as we have found pus and gangrenous matter do, 
§ 471, 475;) and that their effects, and the general and local re- 
action against them, (§ 17,) lead to the various degrees and forms 
which we find erysipelatous inflammation and its accompanying 
fever present. The same morbid matter, being transferred by 
any of the three modes of infection (§ 94) to other persons, may 
induce erysipelas in previously existing inflammation, or if strong 
enough, may develop it anew in the body. The fact that patients 
often sicken with fever (rigors, vomiting, headache, quick pulse, 
delirium, &c.) before the erysipelatous inflammation appears, is 
a sufficient proof that the poison acts on the constitution as well 
as on a part; and the fact that weakly persons, and those with 
previous structural disease, (especially of the kidneys,) chiefly 
suffer from the worst effects of erysipelas, shows the essentially 
depressing operation of the poison. 

Some asthenic inflammations of mucous and serous membranes 
and internal organs exhibit many of the constitutional effects of 
the worst forms of erysipelas; they sometimes prevail when it is 
epidemic, and may be traced to the same infection. This may 
be said especially of puerperal metritis and peritonitis, erysipe- 
latous, tonsillitis and laryngitis and suppurative phlebitis. 

483. Pelliculur or diphtheritic inflammation of mucous mem- 
branes has some affinity to the erysipelatous, being diffused and 
spreading, generally asthenic, and accompanied with a low kind 
of fever. It is attended with more soreness than pain, little 
swelling, and a deep redness, which is early obscured by the 
characteristic film of* grayish or dirty white albuminous matter, 
which is exuded on the inflamed surface. Patches of this kind 
often occur on the tonsils in sore throat, and have been commonly 
mistaken for sloughs. In certain epidemics, often connected with 
scarlatina, a diphtheritic inflammation affects the whole throat, 
am I sometimes extends to the trachea and air-tubes, the mouth, 
the gullet, and more or less of the alimentary canal. The films 
of lymph thus effused are often foetid, apparently from incipient 
22 



254 PROXIMATE ELEMENTS OF DISEASE. 

decomposition, which is promoted by their exposure to air and 
moisture in the throat and air-passages. As in the case of dif- 
fused suppuration and gangrene, this result of inflammation thus 
tending to putrefy is at once a sign of the low condition of the 
vital powers, and a cause of their further depression. 

The exudation of lymph instead of mere mucus or purulent 
mucus as usual, I am disposed to refer to the inflammation affect- 
ing the submucous cellular tissue, and being at the same time dif- 
fused like erysipelatous inflammation. Deep-seated inflammation 
of a more sthenic character is circumscribed by the effusion caus- 
ing a thickening of the membrane, as in laryngitis: but the matter 
effused by diphtheritis, although fibrinous, is thin enough to trans- 
ude through the mucous membrane on the surface of which it 
concretes. The thinness of the mucous membrane of the air- 
passages in children facilitates the transudation in their deep- 
seated inflammations: hence, at an early age, all such inflamma- 
tions may cause an effusion of fibrinous matter, as we find 
exemplified in croup. So, too, the extreme tenuity of the mucous 
lining of the smaller divisions of the air-tubes makes the exuda- 
tion of fibrinous matter a common result in pneumonia and some 
kinds of capillary bronchitis. This is exemplified in the rami- 
form moulds of the bronchial tubes sometimes expectorated. 
Similar skinlike exudations are sometimes passed from the intes- 
tines after the irritation of calomel or other strong purgative, and 
in some cases without any such irritation. I have at present 
three patients under my care, who from time to time pass from 
the bowels a quantity of shreds like white kid leather, without 
any symptoms of active inflammation: congestion seems to be a 
chief cause in these cases, (§ 308.) 

In the mouth and throat, various asthenic inflammations seem 
to be capable of causing a fibrinous exudation, as that from mer- 
curial action, and that in the aphthous mouth and throat of adults, 
which occurs towards the fatal termination of various chronic 
diseases. The aphtha? of children are different, being vesicular 
elevations of the epithelium, with or without a fibrinous film un- 
derneath. 

484. Hsemorrhagic inflammation is entitled to be considered 
as a distinct variety. In most inflammations there are slight ex- 
travasations of blood; but sometimes there is so much colouring 
matter in the inflamed texture and in the products effused, that it 
may be difficult at first to say from the appearance whether the 
disease is a haemorrhage or an inflammation. These inflamma- 
tions I have found to be asthenic; often the subjects were scor- 
butic, or affected with purpura; and, as I have stated with regard 
to the latter disease, (§ 358,) there has been distinct evidence of 
imperfect action of the liver and kidneys. Thus I have met with 



INFLAMMATION VARIETIES SCROFULOUS. 255 

hsemorrhagic pleurisy and pericarditis in conjunction with cirrhosis 
of the liver and Bright's disease of the kidney. An altered con- 
dition of the colouring matter (§ 186) is perhaps more concerned 
in causing this result than a deficiency of the fibrin, to which it 
is commonly ascribed. 

485. Scrofulous inflammation is decidedly asthenic, and exhi- 
bits many deviations from the common form of inflammation. 
It may be well exemplified in the lymphatic glands, one of its most 
common seats, and within the reach of direct observation. These 
glands, in common inflammation, become very painful and hot, 
as well as swollen, and the inflammation tends soon either to re- 
solution or to suppuration. In scrofulous inflammation, on the 
other hand, lymphatic glands swell to a great size; and often the 
deep redness extends to the surface, but with little pain or heat; 
and the swelling remains for a very long period without either 
resolution or suppuration, and little influenced by antiphlogistic 
remedies. Sometimes it seems to suppurate, so that the swelling 
becomes distinctly fluctuating, very red, and ready to open; but 
afterwards the skin becomes wrinkled, and the swelling subsides. 
When it does burst, or is opened, the pus is serous and curdy, or 
mixed with matter of a soft cheesy consistence, (soft tuberculous 
matter;) and the abscess thus opened leaves a deep ulcer with a 
narrow orifice, (fistula,) which is indisposed to heal. The kind 
of inflammation of which this is one example, occurs in persons 
of what is called the scrofulous diathesis or constitution. 

The scrofulous diathesis is merely a term employed to desig- 
nate a state of the body in which scrofulous inflammation and 
malnutrition are apt to occur. It has been generally stated that 
this diathesis has certain outward marks, by which its existence 
may be recognized independently of the actual occurrence of 
disease. Thus a relaxed state of the muscles, a soft transparent 
skin, a fair or pale complexion, with partial patches of a peculiar 
pink or purplish redness; a pearly whiteness of the eye and teeth; 
tumid upper lip; fair or reddish hair; large and weak joints; pre- 
cocity of intellect, and some other signs, have been described as 
characteristic of the scrofulous diathesis. But such marks are met 
with without any manifestation of scrofulous disease; and still 
more frequently, scrofulous disease is induced in persons quite 
destitute of these characters. 

More constant concomitants of the scrofulous disposition 
(although they sometimes occur without scrofula) are, various 
signs ol weak circulation and imperfect nutrition, such as cold 
extremities; weak, but easily accelerated pulse; small development 
oi' muscles; uncertain digestion and irregular excretion; slow or 
defective healing of wounds; The circumstances which most fa- 
vour the production of the scrofulous diathesis are also causes of 



256 PROXIMATE ELEMENTS OF DISEASE. 

a weakening kind, especially when these are long continued, such 
as poor or insufficient nourishment, especially in childhood or 
youth; cold and damp situations, or defective clothing; long con- 
finement in close, ill-ventilated habitations; long-continued illness, 
especially from eruptive or typhoid fevers; and prolonged and ag- 
gravated disorders of the digestive organs. Scrofula is also, in a 
marked degree, an hereditary affection, (§ 36;) and mere feeble- 
ness of constitution in parents, whether original or from disease, 
or from excesses, or from age, often develops a disposition to 
scrofula in children. 

In persons of the diathesis now noticed, inflammation fre- 
quenlty runs a course, and leads to results different from those of 
inflammation in a healthy subject. Commonly the inflammation 
is more asthenic, (§ 477;) often it is more subacute or chronic 
(§ 479) than usual; but in all cases, its solid producis are not 
euplastic, (§ 450,) as in healthy persons; and may be either 
cacoplastic (§ 4 52) or aplastic, (§ 453,) according to the preva- 
lence of the scrofulous constitution, the texture affected, and the 
quantity of the inflammatory product thrown out. Where the 
scrofulous diathesis is most developed — where the texture in- 
flamed is an internal one, not freely discharging externally — and 
where the product of inflammation is most copious, — there the 
deposit will be most aplastic, consisting of scrofulous pus or yel- 
low tubercle, devoid of regular structure, and wholly insusceptible 
of organization; and being not fit for absorption, it operates as a 
foreign body, irritating, obstructing, and compressing the adjoin- 
ing parts, in various ways detrimental to their functions and 
structure. Thus arise tuberculous or scrofulous deposits and 
abscesses in lymphatic glands, in bones, cartilages, and in the 
connected cellular textures, tuberculous infiltrations in the lungs, 
and deposits in serous cavities. Where the scrofulous diathesis 
is less pronounced, and the inflammatory effusion less copious 
and more gradual, the result may be a cacoplastic product, sus- 
ceptible of only a low organization; as gray, miliary, and tough 
yellow tubercle; cirrhosis, atheroma of arteries, fibro-cartilage, 
and other degraded living solids. These have been already no- 
ticed, (§ 453, 454,) and will again come under consideration as 
products of altered nutrition. The aplastic tendency of inflam- 
mation in scrofulous subjects is sometimes manifest in other ways 
in different textures. Synovial membranes of joints are softened 
into a brownish pulp, (Brodie;) articular cartilages and the cornea 
ulcerate, from absorption predominating over effusion, (§ 466;) 
the integuments of the face and other parts inflame in small 
cutaneous tumours or tubercles, which ulcerate, and the ulcers 
are phagedenic, spreading and destroying the nose or adjacent 
parts, as in lupus. 



INFLAMMATION VARIETIES SYPHILITIC. 257 

It seems, then, that the most constant peculiarity of scrofulous 
inflammation is, that it degrades or arrests nutrition by supply- 
ing a material in a condition little or not at all susceptible of 
organization. This leads us to inquire what is the condition of 
the blood in scrofula; and we are answered by the interesting 
result obtained by Andral and Gavarret before mentioned, (§ 454,) 
that there is an excess of fibrin, (§ 195,) but a deficiency of red 
particles, (§ 185.) The fibrin is, however, defective in vitality; 
and this seems to favour the hypothesis that the red particles are 
concerned in preparing this plasma, (§ 210;) where they are de- 
ficient, it is ill prepared. 

486. Gouty and rheumatic inflammations have already been 
noticed in relation to their specific cause, a morbid matter in the 
blood or in the textures, (§ 251, 254;) and some of the peculiar 
characters of the inflammation were then adverted to, (§ 385.) 
It is highly probable that the peculiarities of many other inflam- 
mations, especially of the skin, may be referred to a similar cause, 
a particular matter in the biood irritating the parts through which 
it circulates, (§ 402.) 

487. The poisons of gonorrhoea and syphilis excite inflam- 
mations still more peculiar in their phenomena and course. 
Gonorrhceal inflammation chiefly affects the genito-urinary pas- 
sages and the conjunctiva. It is generally acute, and results in 
the secretion of an opaque sulphur-coloured pus, which is capable 
of propagating the disease. Sometimes it affects the testicle also 
with acute inflammation, and the joints with more chronic, con- 
stituting gonorrheal rheumatism. 

Syphilitic inflammation exhibits great varieties in site and 
effects. Locally, the syphilitic poison may excite on any thin- 
skinned surface a papula, or small tubercle, which, ulcerating, 
forms a chancre. As the matter is absorbed from this, it causes 
inflammation with great pain and swelling of the neighbouring 
lymphatic glands, (bubo,) which may suppurate. These are pri- 
mary inflammations, and of an acute character. When absorbed 
into the system, it may excite secondary inflammations; sore 
throat, generally asthenic, and tending to ulcerate; and a great 
variety of inflammations of the skin, which vary greatly in their 
type as well as in their character, according to the vigour, &c. of 
the subject. They often leave a peculiar lurid or copper-coloured 
Stain in the under layer of the epidermis, which obviously arises 
from an extravasation of some colouring matterof the blood, and 
probably implies a change in it. The periosteum and bones are 
also often attacked with syphilitic inflammation; and painful nodes, 
exostoses, suppuration, and caries, may result. The iris is some- 
times attacked with acute inflammation and effusion of lymph, 
which may endanger sight if not reduced. 
22* 



258 



PROXIMATE ELEMENTS OF DISEASE. 



TREATMENT OF INFLAMMATION. 

488. We have found inflammation to be an essentially com- 
plicated process, composed of several constant elements, to which 
are frequently added others, which further increase the com- 
plexity of the disease. A proper knowledge of these elements, 
and of the means which best remove or counteract them, sepa- 
rately and in combination, forms the best guide to the rational 
treatment of inflammation, and supplies a safe clue through the 
confused and paradoxical assemblage of agents which experience 
has proved to be antiphlogistic remedies. As we have not time 
to discuss in detail the elements and results of inflammation with 
regard to treatment, it will be very useful to enumerate these 
elements and results, with references to the text, which more 
fully explains them, and then to represent in a tabular view the 
remedies that may be opposed to these elements and results, 
various combinations of which remedies constitute the anti- 
phlogistic treatment. 

489. Constituents of Inflammation. 



Essential ele- 
ments of in- 
flammation, 
(Local.) 



From operation (""Congestion, (§ 403, 407,) 

of < or 

exciting cause. (^Nervous and vascular irritation, (§ 402, 408.) 

''Determination of blood towards the affected part, (§ 409, 419.) 

Obstruction of the vessels most affected, (§410,419;) by atonic 
enlargement of the capillaries, (§ 414;) by production and 
adhesion of white corpuscles in the vessels, (§415.) 

Distension of arteries and capillaries before the obstruction, 
(§ 420,) causing increased effusion (§ 423) of serum, lymph, 
pus, &c. (§ 427.) 

Emptiness of veins beyond the obstruction, (§ 427,) causing 
increased absorption, (§467,) hence softening, &c. 

Impeded or arrested circulation at the obstruction, (§418,) 
causing a reduction or abolition of vital properties, (§273,) 
hence the death of the part, and its removal by ulceration 
(§ 466) and suppuration, (§ 427,) or its decomposition by 
gangrene, (§473.) 

Increased circulation of blood abound the obstruction, (§ 410,) 
causing exaltation of vital properties, (§ 421, 333;) hence 
spasm, (§ 1 13,) pain, (§ 135,) sympathetic irritations, (§ 149,) 
increased secretion, (§ 159,) &c. » 

'"Extension of the excitement to the heart and arteries, (§ 440,) 
causing inflammatory fever. 

Change in the whole blood, by increase of fibrin from the in- 
flamed part, (§438,) and by diminution of the excretions by 
the inflammatory fever, (§ 441.) 

Exhaustion ensuing after the excessive excitement (§116) or 
the effusions of inflammation, (§ 459, 470.) 

Depression, sometimes with partial irritation, from the pre- 
sence of pus or gangrenous matter in the blood, (§ 470, 475.) 



Constitutional 

effects of 
inflammation, 
(not essential.) 



INFLAMMATION TREATMENT OF ITS CONSTITUENTS. 259 



490. TABULAR VIEW OF THE CHIEF ELEMENTS OF INFLAMMATORY DIS- 
EASE, AND OTHER REMEDIES. 

CONSTITUENTS OF INFLAMMATION. ANTIPHLOGISTIC HEMEDIES. 

1. Congestion C Astringents; stimulants; evacuants; .|_^ 

b i (§315, etseq.) I s g 

2. Irritation of nerves . . . Narcotics; counter-irritants; (§ 137,155.) { .g g 
C Sedatives; derivatives; evacuants; | % ,§ 

• 1 (| 342, ci scy.) J Pm .3 



3. — of vessels, 



4. Determination to the part. . ^^^^^^^^^ 



5. Obstruction in the part: 

— by atonic enlargement Remedies for congestion, (see above) 

6. - by adhesion of corpuscles {^^ Q ° l ^^ ; attenuants? 

7. Distension of vessels . . . £ °S^f J^^*! 6 ? 11 ^ ^ 

C Evacuants; derivatives; operations; 
' ? sorbefacients? 



Effusions 



TDirect remedies not known; stimu- 
9. Increased absorption . . . < lants; diminishing atmospheric 



pressure on the parti 

10. Impeded circulation in the part Moist heat and other stimulants . . 

,, T „ „, •.„ i .• „ „. j C Remedies for determination, (see 

11. Increased circulation around <,_.„_< 



above) 



12. Excitement of the heart 



2 S3 






C General blood-letting and other eva- 
£ cuants; sedatives; (§ 115) . . . 
TGeneral blood-letting and other eva- 

13. — of the arteries generally < cuants; relaxants, (antimony, &c, 

C § 122;) salines] IgjJ 

14. Change of the blood: 

k ' n „,«,«„f^nn C Blood-letting and other evacuants; 

- by increase of fibrin . ^ (§ 214;) mercury; low diet . . . 

15. - by diminution of the ex- 1 Evacuant alteratives . (§ l72 , e t 8 eg.) 

cretions .... 3 * * 

16. Exhaustion Stimulants and tonics, (§ 119, 124.) ~ 

17. Depression from poison . . Stimulants; antiseptics; evacuants; (§ 260.) 

18. Solid products of inflammation \ Attendants? alteratives? sorbefacients? sti- 

1 \ mulants; pressure, and friction. 

491. My limits will not enable me to do more than offer some 
brief comments on the principles of the treatment, and to exem- 
plify the above table by the results of experience. 

1. Congestion. The efficacy of topical astringents and stimu- 
lants in the congestion preceding inflammation, is illustrated in 
the effect of a strong solution of nitrate of silver or sulphate of 
zinc in curing conjunctival ophthalmia, and of the s;iiih: ;igcnts, 
or powdered alum, (Y r elpeau,) or capsicum gargles, in curing an 
incipienl sore throat. But as with reg;ird to congestion, (§ 317,) 
so still more in the congestive stage of inflammation, if it be ex- 



260 PROXIMATE ELEMENTS OF DISEASE. 

tensive, long established, or already complicated with determina- 
tion of blood, stimulants and astringents do no good, and may- 
aggravate the inflammation; and it is especially under these cir- 
cumstances that evacuants, derivatives, and even blood-letting, 
may be requisite. The utility of these has been mentioned under 
the head of congestion, (§ 318;) but they may be more necessary 
in the congestive stage of inflammation, inasmuch as it tends to 
further and worse results. A strong purgative and diaphoretic, 
if given early enough, may suffice to remove an incipient inflam- 
mation; but if this inflammation be extensive, especially when the 
subject is plethoric, the proper remedy, even at this stage, is 
blood-letting, local or general, according to the situation and 
extent of the inflammation. 

492. — 2 and 3. Irritation of nerves and vessels. The irritation 
of the nerves, which we have found to constitute a part of the 
commencement of some inflammations, (§ 402,) is so closely fol- 
lowed by irritation of the vessels that their remedies are much 
the same. The efficacy of a large dose of opium in incipient 
inflammation exemplifies the utility of narcotics in subduing 
nervous irritation, and these remedies are the more indicated 
where pain, and other signs of excited nervous function (§ 151) 
predominate. On the other hand, where heat and redness rather 
prevail, the vessels are more excited, and the more appropriate 
remedies are sedatives, such as cold and saturnine lotions to the 
part, and various evacuants and derivatives, which draw the 
blood away from the excited vessels. Counter-irritants or re- 
vulsives of the most speedy operation, such as heat, dry and 
moist, mustard poultices, and other stimulating applications near 
the affected part, seem to act both on the nerves and vessels, and 
are powerful means of subduing the irritation which leads to 
inflammation. In these applications the effect on nervous irrita- 
tion is proportioned to the sensation which they produce, and 
where pain or other signs of nervous excitement predominates, a 
heat almost scalding or burning, or stimulating agents which 
cause severe smarting, are most effectual. On the other hand, 
where the vessels are excited, as evinced by heat and redness, (if 
visible,) counter-irritants or revulsives which act extensively 
rather than intensely are of more avail; such as a general or 
partial hot bath, or large poultice, or fomentation, made more 
stimulant by various additions. On the same principle purga- 
tives and other evacuants continue to be indicated. Emollient 
and demulcent remedies, where they can be directly applied, often 
soothe an inflamed surface, both by promoting the natural secre- 
tion, by removing irritating matter which may have caused the 
inflammation, and by reducing the acrimony of the morbid dis- 
charge, which is often acrid, (§ 455.) 



INFLAMMATION TREATMENT OE ITS CONSTITUENTS. 261 

493. — 4. Determina lion to the -part. This, with the following 
element, obstruction in the part, is only the further result of 
irritation of the vessels; hut it is here named as a constituent of 
established inflammation. It is to be opposed by the same reme- 
dies as those just mentioned for vascular irritation, and formerly 
noticed as suitable for simple determination of blood, (§ 342, et 
seq.,) but as part of a disease which is more enduring and serious, 
the determination attending inflammation requires a fuller than 
usual application of these remedies. Of the sedatives applicable 
to this element, none is so effectual as cold, which we have found 
more than any other agent to promote the contraction of arteries, 
(§120.) It is thus that ice and cold lotions are very salutary in 
reducing active inflammation where they can he properly applied, 
as in external inflammations; in some internal inflammations the 
cold may be made to reach the interior, as by a bladder of ice 
to the head in meningitis, and by swallowing slowly small pieces 
of ice in gastritis. Cold will do harm instead of good in inflam- 
mation, either when it does not reach the enlarged arteries through 
which the determination takes place, (§ 326,) or when it is not 
sustained long enough to prevent the effects of reaction, (§ 79,) 
by which the arteries again become enlarged and determination 
is renewed. For these reasons, external cold applications are 
injurious in most internal inflammations, and if not steadily regu- 
lated, they may prove so in other cases likewise. 

Warmth and other derivants applied to parts more or less 
remote from the vessels which are the channels of determination 
are very serviceable aids in the treatment of this element: thus, 
partial or general warm baths, hot poultices, &c, operate. Dia- 
phoretics which equalize the circulation without stimulating, such 
as antimony, are also beneficial, by relaxing the cutaneous ves- 
sels generally, and thus deriving to the whole surface. So we 
have found (§ 345) purgatives and diuretics to operate as deriva- 
tives as well as evacuants; and blood-letting was then stated to 
be the most effectual of all, (§ 346.) Change of posture by ele- 
vating the part inflamed, should also be mentioned among the 
means which counteract determination of blood. 

These different measures, which may suffice in simple determi- 
nation, may be insufficient for that attending inflammation, chiefly 
because they cannot easily be sustained for a length of time. To 
produce a more permanent derivation or revulsion, as well as to 
;ui ;is counter-irritants, various agents are used to excite artificial 
inflammations, which counteract inflammatory disease by deriv- 
ing and irritating in another direction. To this class belong blis- 
ters, mustard poultices, applications of tartar emetic, croton oil, 
strong ammonia, mineral acids, some essential oils, heat above 
120° Fahrenheit, &.c, varying in the amount of inllammation 



262 PROXIMATE ELEMENTS OF DISEASE. 

which they excite according to the manner and duration of their 
application. As these fulfil several indications in inflammation 
they will again come under our notice. 

494. — 5 and 6. Obstruction in the part by atonic enlargement 
of the capillaries and by adhesion of the white corpuscles. 
These two are classed together, because they both contribute to 
produce the partial obstruction which is characteristic of inflam- 
mation. The atonic enlargement of the capillaries may be thought 
to be included in the congestion before noticed; but it stands here 
as a part of established inflammation, and therein different from 
mere congestion, (§ 287.) The remedies to be opposed to it are, 
however, the same as those mentioned under that head; but here 
they generally occupy a subordinate place, unless they fulfil other 
indications. There are, however, a few cases in which the treat- 
ment for congestion, even by stimulants, proves effectual in curing 
inflammation. Catarrhal inflammations of mucous membranes 
are sometimes removed by a highly stimulant treatment with 
wine, spirits, or ammonia. It is probable that the circulation is 
so much accelerated as to excite the dilated vessels to contract, 
and the obstruction is thus swept away. This treatment gene- 
rally causes sweating and a deposit in the urine; but these seem 
to be as much the effects as the causes of the improvement, for 
sweating by other means is not so effectual. But this mode of 
treatment is hazardous, for it acts by increasing the flow of blood, 
and if this fail to remove the obstruction, it will surely aggravate 
the inflammation. 

But the most constant and important part of the obstruction of 
inflammation is due to the unusual formation and adhesion of 
the white corpuscles in the inflamed vessels; and inasmuch as it 
is this especially that establishes inflammation and is the cause 
of its most serious results, it would be most desirable to find 
some remedial influence to counteract it. Unfortunately, how- 
ever, we are not acquainted with any direct means of preventing 
the formation and cohesion of these globules, or of dissolving 
them when formed. As these globules appear to be formed in 
the blood-liquor, we should look for the desired remedies among 
the medicines which affect the blood; and it might be surmised 
that alkaline and other salts may possess this virtue. The effi- 
cacy of carbonate of potash as an antiphlogistic remedy has been 
much vaunted by Sarconi and other Italian writers; but this is 
not confirmed by general experience. In fact, it appears, from 
the experiments of Mr. Blake, (§ 214,) that salts of potass in- 
jected into the veins promote the coagulation and stagnation of 
the blood instead of preventing them. Whether antimony or 
mercury possesses any such quality is not known; the subject 
deserves careful experimental investigation; for if a medicine 



INFLAMMATION TREATMENT OF ITS CONSTITUENTS. 263 

could be found capable of fulfilling this intention, it would be the 
most efficacious of all antiphlogistic remedies. It cannot be 
doubted that blood-letting and other evacuants which reduce the 
mass of blood also diminish the white corpuscles as well as the 
fibrin, (§ 214;) but they do so at a great expenditure of the red 
particles, and therefore of vital power, (§ 183.) 

495. — 7. Distension of vessels. This is another of the more 
characteristic constituents of inflammation, and has been ex- 
plained to be the result of determination of blood into congested 
and obstructed vessels. In congestion, we formerly found dis- 
tension sometimes to occur, (§ 306;) but there it is chiefly in the 
veins; here it is in the small arteries, and all those parts of the 
capillaries that are on the arterial side of the obstruction. This 
may account for the greater degree of distension, and the larger 
amount of effusion and other changes that result from it. We 
see, too, that the most effectual means of relieving it will be by 
lessening either the determination of blood or the obstruction. 
The measures for reducing the determination must be now of 
the stronger kind, such as blood-letting and free derivation or 
evacuation; because the arteries which are the seat of determina- 
tion are closed at most of their capillary ends, and must be drawn 
upon either directly or through means which reduce the pressure 
in the arteries generally. Where, therefore, there is any con- 
siderable determination of blood, the distension which it causes 
will not be relieved without drawing blood either from the en- 
larged vessels themselves, or from other parts, in sufficient quan- 
tity to reduce the general arterial pressure. 

Other slighter means give some relief to the distension of the 
vessels in inflammation. External pressure, carefully equalized, 
can sometimes do this, as in the effect of well-applied bandages 
and strapping on wounds. Fluid pressure, as proposed by Dr. 
Arnott, by means of quicksilver, or the slack air-cushion under a 
bandage, might be still more useful in various external inflam- 
mations, because its equality insures its proper application. It 
is very probable that a part of the efficacy of poultices depends 
on the soft and uniform pressure which they produce on the in- 
flamed vessels. But certainly poultices, fomentations, and other 
means of applying moist heat, relieve distension in the part also 
by relaxing the solid fibres, and by promoting the exudation of 
the watery parts of the blood. 

496. — 8. The effusions from, the vessels are the result of their 
continued distension. They may therefore be prevented or less- 
ened by means which reduce this distension; but in severe cases 
of inflammation, effusion is the natural mode in which the vessels 
arc relieved of their load; and we have just mentioned that 
poultices and fomentations give relief by promoting this result. 



264 PROXIMATE ELEMENTS OF DISEASE. 

If the effusion is outwardly, as from a mucous membrane, it may 
not be necessary to check it, except so far as it may interfere 
with the functions of the part; but if it be too thick, alkaline 
medicines sometimes succeed in attenuating it, and thus promote 
its discharge; whilst acids and various astringent remedies check 
it when it is too profuse; but here blisters and various evacuants 
should be combined with these last, otherwise the inflammation 
may be increased. This corresponds with what has been said of 
the treatment of sthenic fluxes, (§ 393.) When the effusion is in 
cellular texture, a serous cavity, or parenchyma, it may more 
seriously interfere with the functions of the part; and it may be 
more important to prevent, or restrain, or remove, the effusion. 
Thus, in the submucous cellular texture of the glottis, or in the 
serous membranes of the brain, a little effusion may prove fatal; 
and in the lungs or pleura, effusions are injurious in proportion 
to their extent. Besides the measures directed against deter- 
mination and vascular distension, it is doubtful that we possess 
means of restraining effusion. It is pretty certain that some other 
antiphlogistic remedies, especially mercury and antimony, do 
diminish the effusions of inflammation, and promote their re-ab- 
sorption; but it is not clear that they do so in any more direct 
way than by reducing the local and general excitement, or by 
their evacuant effect. The expressions, "sorbefacient" and "ex- 
citing the absorbents," hypothetically ascribe to remedies the 
property of increasing absorption; but nothing in physiology 
points out any direct mode in which absorption can be artificially 
increased. A free action of the excreting organs promotes ab- 
sorption, by reducing the distension of the vascular system. Ab- 
sorption is also promoted by a circulation that is free, without 
excitement or distension;* and the return of the vessels to a 
healthy state is generally attended with more or less absorption 
of the effusions. It is probable that blisters and other counter- 
irritant applications near the inflamed part promote absorption, 
not merely as evacuants or derivants, but also by causing a rapid 
flow of blood through the adjoining vessels, which facilitates the 
endosmosis and removal of effused fluids. Hot fomentations and 
stimulant frictions seem to operate in the same way. 

In various cases it is necessary to give vent to the accumulated 

* In my Gulstonian Lectures, (Med. Gaz., July, 1841,) I adverted to the effect 
of a rapid current in promoting absorption. Mr. G. Robinson has lately illus- 
trated this effect by some experiments, (Med. Gaz., May, 1843.) Another influ- 
ence which probably contributes, is the different density of the fluid within and 
■without the vessels: that within is more dense and saline, and by the law of en- 
dosmosis, tends to attract the thinner fluid from without. This explains the 
greater readiness with which the thinner effusions are absorbed. Can we in- 
crease absorption by rendering the blood more saline than usual? The thirst 
after taking salt food would seem referable to this cause. 



INFLAMMATIONS — TREATMENT OP ITS CONSTITUENTS. 265 

effusion by surgical operation, as by incisions or acupunctures in 
erysipelas, opening abscesses, paracentesis in empyema, &c. This 
is chiefly necessary where the effused matter is purulent and little 
susceptible of absorption, as well as noxious to the system; but 
sometimes the mere quantity or situation of the effusion, by en- 
dangering life, renders the resource of an operation necessary, as 
in acute laryngitis and some cases of pleurisy. 

497. — 9. Increased absorption is manifest in the processes of 
softening, ulceration, and suppuration. I have endeavoured to 
explain how, in the midst of distended and effusing vessels, ab- 
sorption is increased. The veins and lymphatics are free, and 
by the motion communicated to them from the current of the 
neighbouring and anastomosing branches, they are ready to con- 
vey away all the fluids that can pass through their coats, (Gul- 
stonian Lectures, 1841.) In fact, this is doubtless a provision for 
the removal of superfluous matter, old and new; but the process 
becomes injurious and destructive when it predominates over 
effusion, and extensively invades the living textures. But we 
have found reason to suppose that textures do not fall a prey to 
the softening or ulcerative process, unless their vitality is lowered 
and their nutrition impaired by a defective supply or quality of 
blood, (§ 466, 7;) and that inflammation does produce these effects 
very differently in different cases. Sometimes local stimulants 
and general tonics check softening and ulceration by improving 
the vitality and nourishment of the obstructed part; but they may 
have the opposite effect if the circulation in the affected part is 
too much obstructed to admit of increase. Hence we find, in 
phagedenic ulcerations, stimulants sometimes check and some- 
times aggravate the disease. The increased absorption which 
forms a part of ulceration might be arrested by diminishing 
atmospheric pressure on the part, as by applying a cupping- 
glass over a phagedenic ulcer; but such an expedient is rarely 
practicable. 

498. — 10. Impeded circulation in the part has been just 
adverted to as contributing, with increased absorption, to the 
processes of softening and ulceration; but its greatest effect is 
manifest in gangrene, or the complete death of the part. In sup- 
puration, also, the part dies, but it is removed by absorption, and 
replaced by pus, which makes its way to the exterior. Of the 
few agents that maybe directed to restore or improve obstructed 
circulation, heat is the chief one to be named. Heat, enlarges 
vessels, especially arteries, (§ 120,) and facilitates the passage of 
blood through them; and although, for this very reason, hurtful 
in sthenic inflammation and in parts where determination prevails, 
it is really very beneficial in the stages ;unl forms of inflammation 
in which obstruction predominates and endangers the vitality of 
23 



266 PROXTMATE ELEMENTS OP DISEASE. 

the part. Hence the utility of hot fomentations or poultices in 
low forms or advanced stages of external inflammation. In slight 
cases, frequent applications of heat and moisture may entirely 
remove the obstruction, restore the circulation, and thus the life 
of the part, although the inflammation may have already caused 
much effusion. In other cases, heat does not remove the obstruc- 
tion, and therefore does not maintain the life of the part; but by 
increasing the determination around it, it promotes its removal 
by suppuration, and it hastens and matures this process, which 
is the best by which a part, the circulation of which is obstructed, 
can be removed. In a similar way, too, heat favours the effusion 
of lymph, which circumscribes the suppuration and prevents it 
from spreading or infecting the system. Lastly, in a similar way, 
heat and other stimulating applications promote the process of 
separation or sloughing of a gangrenous part, (§ 475,) the whole 
circulation and life of which have ceased. These latter effects of 
heat may often be promoted by medicines and food calculated to 
maintain the vigour of the general circulation. 

499. — 11. The increased circulation around the obstructed 
part is often that constituent of inflammation which causes the 
most prominent symptoms, the greatest heat, pain, tenderness, 
and other marks of excited function being commonly dependent 
on it. We have already noticed determination as an element of 
inflammation in its early stage, and refer to that clause (4) for an 
account of the remedies with which it is to be combated. We 
now advert to determination to the neighbouring vessels as a part 
of the extending irritation of inflammation, which often sympa- 
thetically excites the whole system into fever. The treatment, 
therefore, partakes of the character of that suited for inflamma- 
tion with fever. 

Treatment of inflammation with fever. 

500. The fever excited by inflammation consists chiefly of the 
items mentioned in the table; but it will be more convenient to 
notice them here together. They are — (12) Excitement of the 
heart and (13) of the arteries; (14) change in the blood by in- 
crease of fibrin and (15) by diminution of the excretions. 

The addition of fever to inflammation very materially modifies 
the treatment. The disease then to be treated is not merely the 
inflamed part and a few other parts in sympathetic relation with 
it, but the whole vascular system, its blood and the secretions 
and functions which it supports. In like manner, the treatment 
must now become general instead of local; not because the local 
inflammation has lost its importance, but because it has now be- 
come a part of a general disease, winch sustains it with such an 



TREATMENT OF INFLAMMATION WITH FEVER. 267 

energy that local remedies now become trivial, or even injurious. 
Thus, when inflammation is backed by febrile excitement of the 
heart and arteries, the stimulant and astringent antiphlogistic 
remedies (§ 491) irritate the distended vessels instead of making 
them contract. What can local blood-letting do when there is 
an excited force from behind impelling the blood to the inflamed 
part more rapidly than the oozing by local bleeding can relieve 
it? Derivants also have little power when the tension of the 
whole vascular system is so much raised. Counter-irritants 
must even prove injurious, by adding another cause of excite- 
ment to the system. So, too, narcotics can have no control over 
fever once established, and may prove hurtful by exciting the 
nervous centres, and still further impairing the secretions, (§ 166.) 
Under these circumstances, a more general remedy is wanted, 
which shall reduce the action of the heart and arteries, and di- 
minish the inflammatory character of the blood. The first and 
most powerful remedy of this kind is general blood-letting; next 
come the stronger evacuants, antimony and mercury; and lowest 
in power are what are called refrigerants and direct sedatives. 
We shall briefly notice these antiphlogistic remedies. 

501. Blood-letting, if carried far enough, is sure to reduce the 
action of the heart; for, as formerly explained, it may produce 
syncope, (§ 70.) A remarkable fact, first pointed out by Dr. 
Marshall Hall, is, that in inflammatory disease a much larger 
amount of blood may be drawn without producing syncope than 
can be taken in health or in other diseases. The following is Dr. 
M. Hall's table of the results of his investigation of the tolerance 
of blood-letting in different diseases. The numbers represent the 
mean quantity of blood which flows before incipient syncope in 
the sitting or erect posture: — 

I. Augmented Tolerance: 

Congestion of the brain ^ xl — 1. 

Inflammation of serous membranes ~) 

Inflammation of synovial membranes .... S-$ xxx — xl. 
Inflammation of fibrous membranes S 



Inflammation of the parenchyma of organs, (brain, ) ~ 
lung, liver, mamma, &c.) 5' 



v xxx. 
Inflammation of skin and mucous membranes (ery- 



sipelas, bronchitis, dysentery) 5° 

II. Healthy Tolerance: 

This depends on the age, sex, strength, &c, and} 
on the degree of thickness of the parietes of theC-g xv. 
heart; and is about J 

III. Diminished Tolerance: 

Fevers and eruptive fevers 5 xii — 3 xiv. 

Delirium tremens and puerperal delirium .... 5 x — xii. 



268 PROXIMATE ELEMENTS OF DISEASE. 

Laceration or concussion of the brain . . . . "^ 
Accidents before the establishment of inflammation £.5 viii — 1. 

Intestinal irritation J 

Dyspepsia, chlorosis § viii. 

Cholera 3 vj. 

The explanation of the increased tolerance of blood-letting in 
inflammation is, I apprehend, to be found in the increased ex- 
citability of the heart and tonicity of the arteries, which maintain 
a sufficient force and tension to preserve the circulation, espe- 
cially through the brain, (§ 266,) even when much blood is lost. 
In asthenic or atonic diseases, on the other hand, the arteries 
being lax, and ill fitted to transmit the blood, a smaller loss is 
felt, and syncope may result. The variations between inflam- 
mations occupying different seats must be referred to the arterial 
tone being less augmented in some than in others, and are there- 
fore indications of the more or less sthenic (§ 477) character of the 
inflammation. The quantity of blood in the whole system will 
affect the heart's action and arterial tension in a similar way; and 
no doubt the more stimulating quality of the blood may contribute 
to the same results. 

502. The object of blood-letting in inflammation is not merely 
to produce syncope, or a temporary impression on the pulse, but 
a permanent reduction of the excitement of the heart and arteries; 
and this is to be effected in different modes of blood-letting under 
different circumstances. Where the inflammation is quite recent, 
and the fever has not existed long, a moderate amount of blood 
rapidly taken from a large orifice, or from two arms at once, or 
even from the jugular vein^will often be sufficient to reduce the 
fever and inflammation. /''The circulation is thus reduced, per- 
haps to syncope; and, relieved of the pressure and determination 
of blood, the inflamed vessels soon recover their normal state, if 
not spontaneously, at least with the aid of some of the subsidiary 
antiphlogistic measures. The benefit resulting from this mode of 
blood-letting in recent cases is sometimes very striking, and the 
cure is effected at a comparatively small expense of blood. 

503. But the case is different when an acute inflammation and 
fever have lasted for two or three days. There is then not merely 
excitement, but sundry changes in the inflamed part and in the 
blood, which keep up the excitement; the inflammation has be- 
come established in the part, and the fever in the system; and no 
brief impression on the circulation, however sudden and com- 
plex, can remove them. If in this state a patient be speedily 
bled to fainting, reaction will soon come on, and renew the fever 
with increased intensity. Here, therefore, it is necessary to bleed 
more slowly and to draw more blood; and instead of promoting 
the occurrence of syncope by the erect or sitting posture, it is 



INFLAMMATION TREATMENT BLOOD-LETTING. 269 

proper to keep the patient in an easy recumbent or reclining 
position, and to watch for the good effect of the bleeding in the 
softening of the pulse, or the relief of the pain or other distress- 
ing symptom. The actual occurrence of syncope is rather to be 
avoided, and may be prevented by untying the arm as soon as 
the lips lose their colour, or the patient complains of feeling sick 
or faint. Thus practised, blood-letting causes a more prominent 
reduction of the active elements of inflammation and fever, dimi- 
nishes the exciting and too fibrinous condition of the blood, and 
although it camiot repair the changes already produced in the 
inflamed part, it prevents their increase, and puts them in a con- 
dition favourable for the curative efforts of nature and the further 
operation of other antiphlogistic remedies^/ In the more severe 
and confirmed cases of inflammation it is~often requisite to repeat 
the blood-letting again and again; the indication for this being 
the return of incompressibility of the pulse, heat of skin, and a 
new aggravation of the symptoms. In all such cases, the ad- 
vantage of the gradual over the sudden mode of blood-letting is 
apparent, for where the reducing influence of this measure is 
longest sustained, it is least necessary to resort to it again. 

Another case in which it is expedient to draw blood largely 
rather than suddenly is where inflammation is combined with 
plethora. On the other hand, in anaemic subjects, the blood should 
be economized as much as possible; the early depression from 
the loss of blood should be promoted by a posture favouring the 
occurrence of syncope, and might be sustained by the influence 
of antimony and other remedies. 

504. After the general excitement has been lowered or re- 
moved by general blood-letting, the local inflammation often has 
to be treated by topical blood-letting, which now is not only more 
efficacious in reducing the determination and distension of the 
inflamed part, but contributes to keep down the general excite- 
ment. In fact, local blood-letting, as by cupping or numerous 
leeches, may be made so extensive as to be tantamount to general 
blood-letting; and the cases in which it has most of this effect 
are those in which slow bleeding answers best. In either ex- 
treme of age, and in the feeble, local bleeding only is admissible. 
Local blood-letting is chiefly suitable for inflammations which are 
superficial and extended, as those of the pleura or peritoneum. 
It is of much less avail in pneumonia, ccrcbritis, and other in- 
flammations of deep-seated or parenchymatous organs. 

505. Of Other evacuants none arc equal to purgatives, which 
are a greal aid to blood-letting, and should be used in most cases 
of severe inflammation, uncomplicated with gastro-enteritic irri- 
tiiiinii. They operate on so large a surface that they affect the 
system, and their effecl may 1"' pushed to the extent of producing 

23* 



270 PROXIMATE ELEMENTS OF DISEASE. 

syncope; but such an extreme result is attended with much ex- 
haustion, and their continued use may cause intestinal inflamma- 
tion. The chief benefit arising from purgatives may be obtained 
from a few efficient doses at the commencement of the treatment. 
This aids the depressing effect of blood-letting, removes fasculent 
matter, which is often a source of irritation, and clears the intes- 
tinal canal for the operation of other medicines. The stronger 
and less heating purgatives are to be preferred, such as calomel, 
jalap, salts and senna, combined with tartar emetic or colchicum. 
A combination of several, which operate most on different parts 
of the canal, answers best. 

506. Of internal remedies against inflammation with fever, that 
which most resembles blood-letting in its effects is tartarized anti- 
mony. It is far less sure in its operation, and its influence is 
not proportioned to the quantity; yet under its use, especially if 
preceded by blood-letting, the pulse becomes less hard and fre- 
quent, the heat of skin is moderated, and sometimes perspiration 
ensues, whilst the local symptoms are generally more or less im- 
proved. Sometimes it causes vomiting, more rarely purging; but 
its best antiphlogistic operation occurs where these effects do not 
ensue to interfere with a continuance of the medicine; and I have 
frequently found its utility most marked when it did not cause 
even nausea or profuse diaphoresis. Tartarized antimony, and 
the milder preparation, James's powder, have been very long 
used in this country as febrifuge medicines; and Dr. Marryatt, 
who practised at Bristol in the last century, used the former in 
large doses for inflammation. The practice was since carried to 
a greater extent by Rasori, and other Italian physicians, who 
gave from 10 to 120 grains in twenty-four hours. Laennec 
adopted the use of the remedy in more moderate quantities, giving 
from one to four grains in some agreeable vehicle every second 
or third hour for six doses; then intermitting or continuing it, 
according to circumstances. In pneumonia and rheumatism, he 
considered it the chief remedy. Most practitioners in this country 
now consider tartar emetic a valuable aid in subduing inflamma- 
tion, chiefly to be used after blood-letting; or in slighter inflamma- 
tions, where blood-letting is inexpedient. I rarely find it useful to 
raise the dose beyond two grains every three hours; and in most 
cases one grain, half a grain, or even less, will suffice. The first 
doses sometimes cause vomiting; but this generally subsides when 
the doses are repeated, and may be prevented by giving the 
medicine in a mild neutral saline draught, with from five to ten 
minims of the diluted hydrocyanic acid in it. Antimony acts 
most satisfactorily in inflammations of vascular parenchymata 
and complex membranes; such as the lungs, the testicles, the 
mammae, the air-passages, the cellular membrane and skin, and 



INFLAMMATION WITH FEVER — TREATMENT. 271 

the joints. It is less effectual in inflammation of serous mem- 
branes, and would be unsafe in inflammatory affections of the 
intestinal canal. It is most beneficial in the early stages of in- 
flammation, especially when attended with fever; and seems to 
have little effect on the products of inflammation. 

How antimony operates in reducing fever and inflammation is 
quite uncertain. Rasori considered it to be a direct sedative or 
contro-stimulant, diminishing the excitability of the vascular 
system, and thus neutralizing the inflammation. He supposed 
that the tolerance, or power of the body to bear large doses of 
the remedy, depends on the presence of inflammation in the sys- 
tem; but, as Laennec has observed, this is not correct; for patients 
that are quite convalescent have continued to take 12 or 18 grains 
daily without nausea, or even loss of appetite. Laennec first 
considered that the medicines act as a revulsive, by irritating the 
stomach; but this view being made, by the Broussaians, a ground 
of opposition to the use of the remedy, Laennec latterly repre- 
sented it to act as a sorbefacient. It seems to me, that the most 
reasonable view to take of its operation is, that it chiefly acts by 
diminishing the tonicity of the vascular system, (§ 122.) Small 
doses certainly relax the pulse and skin, and, where there is no 
fever, produce perspiration without stimulating. They also seem 
to increase the biliary and intestinal secretion. In inflammation 
and fever, larger doses are required to produce the same result; 
and as soon as the excessive arterial tension is relaxed, the chief 
part of the fever is removed, (§441.) By thus reducing the in- 
creased tonicity of the arteries, the circulation is equalized and 
quieted, and the determination to and distension of the inflamed 
part are diminished; and the vessels generally are placed in the 
condition for their natural offices of secretion, which their ex- 
treme tension had before interrupted. This view is, however, at 
present, no more than hypothetical, and might with advantage be 
tested by experiments on the lower animals. 

507. Another great remedy in inflammation is mercury, alone 
or combined with opium. The combination of calomel and 
opium was first employed by Dr. Hamilton of Lynn Regis; and 
the rules which he proposed for its use have hardly been im- 
proved on. After a sufficient venesection and a full purge, he 
gave from one to five grains of calomel with from one-fourth to 
one grain of opium every six, eight, or twelve hours. When 
much fever was present with dryness of skin, he added tartar 
emetic and camphor. If no relief ensued in twenty-four hours, 
venisection was repeated. .Most practitioners admit the power 
of this remedy , although some ascribe its efficacy to the mercury, 
others to the opium; and the proportions of each have been va- 
riously altered. The beneficial effects of this remedy generally, 



272 PROXIMATE ELEMENTS OF DISEASE. 

but not entirely, depend on the mercury affecting the system, as 
manifested in adults by the foetor of the breath, and the tender- 
ness and swelling of the gums; and in children, by spinach-like 
evacuations from the bowels. Improvement is, however, often 
manifest before these results take place. In iritis, the influence 
of mercury is quite visible in removing effused lymph; and it thus 
obviously in some way promotes absorption, as well as prevents 
effusion. The same "sorbefacient" operation is seen in the effect 
of mercury in removing the callous margin of indolent syphilitic 
ulcers, and in promoting the spread of phagedenic ulcers. Dr. 
Farre thinks that mercury destroys red particles of the blood, and 
causes in the system a disposition to erythematic inflammation, 
which is incompatible with phlegmonous or plastic; but this is 
opposed by the fact that lymph is thrown out, and granulations 
form and healthy ulcers heal during mercurial action. It will be 
useful to give briefly a view of the operation of mercury and 
opium; for although we cannot be confident as to its entire ac- 
curacy, yet it is founded on what is best known of the effects of 
these medicines, and may therefore be a guide in their adminis- 
tration. 

The opium is useful in preventing the calomel from purging, 
and especially in subduing the nervous irritation attending in- 
flammation, and which we have found to be one cause of that 
sympathetic excitement which, when complete, constitutes fever, 
(§ 440.) Tins salutary effect of opium alone is sometimes seen 
when the vascular excitement has been subdued by a large 
blood-letting, and in cases in which nervous irritation forms a chief 
element of the disease: here a full dose of opium will subdue the 
remains of the inflammation better than any other antiphlogistic 
remedy; it seems to paralyze those sympathies which are con- 
cerned in renewing or maintaining the excitement of inflamma- 
tory fever. So, too, in combination with mercury, the opium 
exercises this narcotic influence; whilst the mercury prevents its 
astringent effect on the secreting organs, (§ 66, 173.) The mer- 
cury acts further: it augments the biliary and intestinal secretions; 
sometimes inducing copious mucous and bilious evacuations; and 
from its effect in iritis, it may be presumed to facilitate the solu- 
tion and removal of effused lymph. How it has this effect is 
quite uncertain; probably it is by changing the condition of the 
blood, by a diminution of the fibrin and white corpuscles, the 
increase of which is much concerned in contributing to the 
changes of inflammation. So we find mercury chiefly useful 
where the blood is very much buffed, and there is tendency to 
copious fibrinous effusions, as in inflammations of serous mem- 
branes and croup. Calomel and opium have little influence over 
high inflammatory fever; and the system thus excited generally 



INFLAMMATION WITH FEVER TREATMENT. 273 

resists the mercurial action. This remedy has no further seda- 
tive effects than those which proceed from its action on the 
intestinal canal; and unless to produce this action, it is not well 
adapted for the earliest stage and most active forms of inflamma- 
tion. In these circumstances, blood-letting is more required with 
mercury than with antimony; and if fever returns during the ac- 
tion of mercury, blood-letting or active purging may be necessary 
to reduce it. In fact, the operation of calomel and opium is less 
antiphlogistic, and more alterative, than that of blood-letting or 
antimony: it is inferior to them in the power of reducing inflam- 
matory fever and active inflammation; but it is superior to them 
in arresting and removing the more plastic products of inflam- 
mation. 

508. As considerable aids in the treatment of inflammatory 
fever, although quite inefficient alone, must be mentioned various 
saline medicines, such as nitrate of potass, and the alkalies com- 
bined with vegetable acids. Diluted solutions of these allay thirst, 
and seem to cool the fever; hence they have obtained the title of 
refrigerants. It is uncertain how far they may operate in diminish- 
ing the cohesion and excess of fibrin in the blood, (§ 438;) but we 
can distinctly trace their good effect in augmenting the secretions, 
particularly that of the kidneys, (§ 256.) They are all more or 
less diuretic; and most of them also supply an alkaline base, which, 
by uniting to the lithic and lactic acids formed in the blood, 
facilitate the separation of these matters by the kidneys. Colchicum 
and digitalis are sometimes reckoned among antiphlogistic reme- 
dies; but in common inflammation, they are of very inferior power. 
In the absence of high fever, colchicum somewhat resembles 
mercury in its special action on the secretion of the liver, and it 
augments the elimination by the kidneys, (§ 257;) and digitalis 
acts as a diuretic, as well as a sedative on the irritability of the 
heart; but during severe inflammation, these effects are scarcely 
produced by doses which it would be prudent to administer. 

509. The utility of counter-irritants as a remedy for several 
elements of local inflammation has been already noticed, (§ 493, 
496;) but their operation is positively injurious in sthenic inflam- 
mation during the prevalence of fever. They then add to the 
excitement of the system; and in proportion to the inflammation 
which they excite, they prove a new source of the inflammatory 
r-haiiLM's in the blood, (§ 438.) But after the fever has subsided 
under the influence of remedies, or is exhausted by time, the ad- 
vantage of counter-irritants returns. Blisters and suppurating 
counter-irritants, which cause copious discharge, are the most 
useful; tending to draw away the remains of inflammation, and 
to promote the removal of effused matters lefl by it. These be- 
come chief remedies as inflammation inclines to a chronic state, 



274 PROXIMATE ELEMENTS OP DISEASE. 

or where it has left such structural changes as cannot be speedily 
removed. 

510. It is not necessary to dwell on the last three items of 
treatment in the table, (16. Exhaustion; 17. Depression from 
poison; IS. Solid effusions.) The exhaustion ensuing after long- 
sustained excitement of inflammation and fever often renders 
stimulants and tonics, as well as a generous diet, necessary in the 
after treatment; but the greatest circumspection is necessary to be 
sure that these measures shall be proportioned to the wants of the 
case, and not pushed so early or so far as to rekindle the inflam- 
mation afresh, or to produce other disorder in the weakened 
organization. Similar aids are required, but are less successful 
in supporting the system against the pernicious influence of 
purulent or gangrenous matter resulting from the inflammation. 
Even in cases of suppuration, the occurrence of the premonitory 
rigors, the diminished strength of pulse and heat of skin, point 
out the time for changing the reducing plan for one more sup- 
porting; but the degree to which the change is made must depend 
on the symptoms and efficiency with which nature is attempting 
the process of limiting the destroyed part. It is probable that, 
in all cases, some purulent or some gangrenous matter finds its 
way into the circulation; therefore, in addition to stimulants and 
tonics, antiseptics (such as chlorinated liquids, nitromuriatic acid, 
and creosote) are sometimes with advantage given internally to 
counteract the septic influence; and the secretions are kept free to 
promote the elimination of the morbid matter, (§ 260.) For a 
similar reason, foul, suppurating, and gangrenous sores are dressed 
frequently, and their discharge corrected and promoted by anti- 
septic and alterative applications. 

511. The removal of many of the products of inflammation 
(serum, liquor sanguinis, and the healthier kind of fibrin and exu- 
dation corpuscles, § 424,) is effected by the natural process of 
absorption, aided by various remedies before mentioned, particu- 
larly blisters and other counter-irritants, mercury, iodide of po- 
tassium, colchicum, and other diuretics. Products of external 
inflammation are sometimes more speedily dispersed under the 
influence of what are called discutients, which are generally slight 
stimulant applications, such as a warm spirit lotion, or solution of 
hydroclilorate of ammonia, common salt, or iodide of potassium; 
and in more chronic cases, by friction with liniments containing 
mercury, iodine, ammonia, and spirit. These operate in various 
ways already explained, by promoting the current of blood 
through the part, and thus facilitating absorption; by diminishing 
the atonic congestion left by inflammation; by promoting secre- 
tion or exhalation; by pressure, &c. 

512. The antiph logistic regim en consists in the exclusion of 






INFLAMMATION TREATMENT OF VARIETIES. 275 

all causes of excitement in the food which the patient takes, and 
in the circumstances to which he is exposed; such as light, noise, 
temperature, exertion, mental excitement, &c. The diet in active 
inflammation should be of the most sparing kind, consisting of 
mere diluents, tea, barley-water or thin gruel, whey, toast-water, 
soda-water, and the like: all stimulants, and articles abounding 
in the protein compounds, (§ 215,) or in oil, (§ 59,) being carefully 
avoided. When fever is present, the total loss of appetite is a 
sufficient guide to the necessary abstinence; and the stomach often 
will not retain or digest much nourishment, especially of a solid 
kind; but this is not the case in all cases of inflammation where 
the restraint is equally necessary. 

TREATMENT OF VARIETIES OF INFLAMMATION. 

513. The sthenic (§ 477) form of inflammation requires the 
whole array of antiphlogistic remedies to be directed with energy 
against it. The prevalence of determination of blood, active vas- 
cular excitement, and the over-fibrinous condition of the blood, 
demands the free use of blood-letting, purgatives, and antimony, 
at the onset; and the full operation of mercury if the disease con- 
tinue. In asthenic inflammation, on the other hand, blood-letting 
is ill borne, and often can only be practised locally; and the chief 
treatment is with antimony or mercury, and blisters, which, in 
the absence of high fever, may be employed at a much earlier 
period than usual. 

514. Jlctite inflammation (§ 478) demands a very prompt use 
of the suitable antiphlogistic remedies; but the choice made of 
them, and the extent to which they are to be pushed, will depend 
on whether the inflammation be sthenic or not. Sub-acute in- 
flammation is generally of the asthenic form; and being less 
severe, as well as slower in its progress and effects, it does not 
require such active treatment. It must not, however, be ne- 
glected; for its obscurity sometimes renders it dangerous; and in 
an insidious manner, it sometimes seriously injures function and 
structure. Its long continuance, or liability to recurrence, renders 
it necessary to continue a moderate antiphlogistic treatment for 
several weeks. When lasting so long, it tends to become more 
asthenic, when the more lowering antiphlogistic remedies are no 
longer serviceable; and sometimes it is proper even to call in the 
aid of tonics and improved diet, whilst the local inflammation is 
treated with counter-irritants. Mercury with opium is generally 
one of the most useful remedies in subacute inflammation. 

515. Chronic inflammation recedes still further from the in- 
flammatory type, and borders more on eongestion or disease of 
nutrition. The absence of fever generally supersedes the need of 



276 PROXIMATE ELEMENTS OF DISEASE. 

the stronger antiphlogistic remedies — those for local inflammation 
being sufficient; general blood-letting is needful only when ple- 
thora also is present; and even local blood-letting should not be 
too freely employed; for it weakens the system, which is generally 
already too feeble in chronic inflammation. Counter-irritants are 
more constantly useful; and their application should be varied ac- 
cording to the seat and extent of the inflammation. In inflam- 
mations of serous membranes, a succession of blisters answers 
best. For chronic inflammations of parenchymatous organs, and 
ulcerations of mucous membranes, counter-irritants, which excite 
pustules, or setons, are of more avail. Mercury is often useful, 
and so are other alterative medicines, especially salines and the 
iodide of potassium. Mercury is more suitable to the more 
sthenic forms, attended with effusion of lymph, leading to tough 
thickening and induration of textures. Iodide of potassium is 
better adapted for chronic inflammation of an asthenic character, 
with reduced blood and strength, with tendency to ulceration, 
suppuration, or aplastic deposits. It is often requisite to keep up 
the general strength by the mildest tonics, such as sarsaparilla and 
mild bitters, and to allow a mildly nourishing, but not stimulating 
diet. Careful attention to the state of the excretions is particu- 
larly necessary. Courses of mineral waters, and change of air 
by gentle travelling, are often serviceable in chronic inflamma- 
tions. 

516. In congestive inflammation, (§ 480,) the treatment for 
congestion should be combined with that of subacute inflamma- 
tion. If the subject be plethoric, general blood-letting would be 
proper; otherwise local bleeding and various derivants or revul- 
sives, among which cupping and dry cupping are the most 
effectual. Rubefacient applications to an extensive surface, as 
large mustard poultices, and strong ammoniacal or mineral acid 
liniments, are of considerable efficacy; and their use can be re- 
newed and varied daily for a long time. Mercury and antimony 
are both highly useful in the more active stage of congestive in- 
flammations: the former especially for inflammations of the abdo- 
men, the latter for those of the lungs. In the absence of much 
irritation, iodide of potassium, mineral acids, and even quinine, 
sometimes help to disperse the congestive part of inflammation. 
So, too, in secreting organs, as the liver, kidneys, and mucous 
membranes, various stimulants which excite the secretion act in 
a similar way. For further particulars, see the treatment of con- 
gestion, (§ 313, et seq.) 

517. The treatment of phlegmonous inflammation* is generally 

* This term is used here in the sense in which Cullen employed it, as op- 
posed to erythematic or erysipelatous. I mention this, because boils or furuu- 



INFLAMMATION — TREATMENT OF VARIETIES. 277 

that for the sthenic form. Erysipelatous inflammation being 
generally asthenic, is not benefited by active antiphlogistic mea- 
sures; and in some cases it is necessary to adopt quite an opposite 
treatment, by ammonia, wine, bark, &e.: this is where the influ- 
ence of the specific poison (§ 482) predominates. In other cases, 
the reaction against this influence is very vigorous, and requires 
moderation. Generally warm fomentations to the affected parts, 
a saline, with small doses of tartar emetic, and keeping the secre- 
tions free, answer best at first, and are, in a few days, to be 
gradually replaced for ammonia or wine, and bark or quinine, 
with improving nourishment. A more decided counter agent 
against the poison (as against other animal poisons) is a deside- 
ratum; but cleanliness and careful regulation of temperature and 
ventilation, are the best preventives. Punctures and incisions, 
which relieve the inflamed part by the discharge of blood and 
morbid matter — and by nitrate of silver, which, by exciting ad- 
hesive inflammation, arrests the progress of the erysipelas — and 
mercurial ointment, which is supposed to modify its character, — 
are the chief kinds of local treatment that have been found useful. 

516. Pellicular or diphtheritic inflammation is usually of an 
asthenic character, little benefited by blood-letting, but chiefly to 
be counteracted by mercury, which is the suitable remedy for all 
inflammations effusing lymph; and by local astringents, or even 
caustics, which, by powerfully exciting the vessels, change their 
action. Thus nitrate of silver, in substance and in solution, 
hydrochloric and diluted nitric acids, (one part to three or four 
parts of honey applied with a brush,) and finely powdered alum, 
have been used with advantage in diphtheritic sore throat. In 
the croupy inflammation of children, the most effectual remedies 
are, calomel freely used, antimony, and certain expectorant or 
attenuant medicines, which promote the more liquid secretions 
of the inflamed membrane. The aphthous inflammation of chil- 
dren is readily subdued by a solution of borax, or a weak solu- 
tion of sulphate of zinc, using at the same time magnesia and 
mild mercurial aperients to correct the secretions of the aliment- 
ary canal. 

517. Hxmorrhagic inflammations (§ 484) are often of the 
congestive kind; and the haemorrhage arises from the excessive 
distension of vessels, as in the haematemesis that sometimes pre- 
cedes gastritis, the bloody discharges of dysentery, and the hac- 
matuna which occasionally ushers in inflammation of the pelvis 
and the tubes of the kidney, (pyelitis.) The hacmorrhagic tend- 
ency exhibited in purpura, and sometimes combined with in- 

cular inflammations are sometimes of an asthenic character; and with them not 
unfrequenlly the constitution requires support. 
24 



278 PROXIMATE ELEMENTS OF DISEASE. 

flammation in lichen lividus, and ecchymosed erysipelas, I have 
often found connected with congestion and torpid action of the 
liver, (§ 171,) and accordingly benefited by mercurial and saline 
aperients, followed by nitric or nitromuriatic acid. 

518. Scrofulous inflammation (§ 485) being generally as- 
thenic, is little benefited by blood-letting or other active anti- 
phlogistic measures. Its disposition to produce early cacoplastic 
and aplastic effusions makes it important that it should be sub- 
dued, if possible, at an early stage, in situations where the forma- 
tion of curdy pus or tuberculous matter would be injurious. In 
scrofulous inflammation of the lymphatic glands, warmth and 
moisture, and discutient applications, (solutions of muriate of 
ammonia, iodide of potassium, warm vinegar,) are often useful 
in dispersing the swelling before it comes to suppuration. In 
internal inflammations in scrofulous subjects, (as of the lungs, 
glands, and joints,) local depletion is generally advisable, followed 
by free counter-irritation, especially such as may cause an ex- 
ternal discharge of pus. Dr. O'Beirne and others recommend 
a free mercurial course for scrofulous inflammation; but this I 
consider admissible only in the earliest stage of the disease, and 
in its more active forms; for I have found (what I believe is the 
experience of most practitioners) that mercurialization greatly 
injures the constitution of scrofulous subjects; degrades the pro- 
ducts of inflammation, and promotes softening and ulceration in 
textures where deposit has already taken place. It seems to me, 
that it is rather asthenic or chronic inflammation, (§ 479,) in sub- 
jects that are not scrofulous, that is benefited by mercury, and 
not that especially occurring in the scrofulous diathesis. Prepara- 
tions of iodine, especially the iodide of potassium, do sometimes 
appear to countervail low scrofulous inflammation; and their 
commonly salutary operation on the constitution renders them 
eligible medicines in scrofulous subjects. 

But the source of the peculiarities of scrofulous inflammation, 
and therefore the chief object for peculiar treatment, is the scro- 
fulous diathesis or constitution; and as this seems to consist in a 
degraded condition of the plasma, or nutritive material of the 
blood, (§211,) often connected with a deficiency of red particles, 
(§ 185,) an invigorating and nourishing treatment and regimen 
are especially indicated, (§218, 219,) and may sometimes be em- 
ployed even when low inflammation is present, this being coun- 
teracted by counter-irritation or other local antiphlogistic mea- 
sures. Hence the best remedies in scrofula are tonics, nourishing 
diet, and other means calculated to improve the nutritive func- 
tion and general health. Of medicinal agents, the iodides of potas- 
sium and iron, and other preparations of iron, bitters with alkalies, 
bark or quinine, and mineral acids, have been found the best aids. 



INFLAMMATION TREATMENT OE VARIETIES. 279 

But still higher in efficacy are pure and mild air, especially near 
the sea or on mountains; warm clothing; regular exercise; warm 
sea-bathing, or cold when borne, (§ 79,) followed by friction; a 
good proportion of wholesome animal food, with due regard to 
the state of the excretions. These measures are of great efficacy 
in the scrofulous diathesis, and are often useful even after inflam- 
mation has produced disease; for they do much to prevent its 
increase, and assist nature in removing or rendering inert the 
cacoplastic or aplastic matter. 

519. The peculiarity in the treatment of rheumatic and gouty 
inflammation consists chiefly in the use of means calculated to 
eliminate the morbid matter, which is its cause, (§ 251 — 254,) 
from the system. The remedies which best promote this object 
have been already mentioned, (§ 252, 254.) But it must be re- 
membered, that the inflammation and fever excited may be so 
high and sthenic, as to require active antiphlogistic measures be- 
fore colchicum or mercury can be made to act; and this is par- 
ticularly the case in acute rheumatism, in which inflammation is 
excited in many parts at once; and probably as a consequence, 
(§ 438,) the blood becomes surcharged with fibrin. Here gene- 
ral blood-letting is necessary, not to remove the cause of the in- 
flammation, but the inflammation itself. If after blood-letting the 
rheumatic cause abound still in the blood, which is commonly 
the case, it is proper then to give colchicum with alkalies, or 
iodide of potassium, or nitre in large quantities much diluted, 
(Gendrin,) and to continue such remedy for some time, until the 
morbid matter shall have been sufficiently eliminated. In asthenic 
cases, the use of bark, quinine, or other tonics, may be service- 
able in improving the tone of the vessels after the irritation and 
exhaustion which the disease and its treatment have produced, 
(§ 174.) 

520. The infectious character of gonorrhoea and syphilis 
proves the specific nature of their cause; but it is only of the lat- 
ter that we can speak of a specific remedy. How mercury cures 
syphilis is quite uncertain. It is not by any property directly de- 
structive of the virus; for the disease cannot be prevented from 
appearing by mercurial action; and when present, it is not always 
cured by it. It is more probable that mercury acts as an altera- 
tive, by removing the callous indurations of syphilitic sores and 
swellings, and by increasing the secretions, and thus gradually 
eliminating the syphilitic virus from the system. It is now well 
known that other remedies, which promote absorption and secre- 
tion, ;ilso promote the cure of syphilis, especially the iodide of 
potassium. Gonorrhoea! inflammation generally tends to a spon- 
taneous cure in a few weeks' time; but tins may be accelerated 
liy mild antiphlogistic and demulcent measures at first, and as- 
tringenl injections and terebinthinate remedies subsequently. 



280 PROXIMATE ELEMENTS OF DISEASE. 



SECTION VIII. 

IDIOPATHIC FEVER. 

[That combination of symptoms known as fever has been de- 
scribed, (§§ 437, 438, 439,*440, 441, 442, 443, 444,) in connection 
with inflammation, and treated of as a consequence of it. We 
have now to consider fever as a general idiopathic affection, 
whose essential phenomena are wholly independent of any local 
inflammation. 

Some of the more prominent reasons for regarding fever as 
essentially distinct from the constitutional effects of inflammation 
will be now briefly adverted to. The characteristic symptoms of 
fever, the causes by which they are developed, the special nature 
of the alterations which occur in the solids during their progress, 
and the epoch at which they happen often posterior to the febrile 
movement, are sufficient reasons for not confounding fever with 
the immediate results of inflammation; a still more cogent argu- 
ment has recently been added by the analysis of the blood in the 
two disorders. 

I. The symptoms of idiopathic fever are chilliness, and lassi- 
tude, followed by subsequent reaction, with often long continued 
acceleration of pulse and heat of skin, and attended with thirst, 
anorexia, general uneasy sensations, and disturbance of all the 
functions. All these phenomena may occur without the evidence 
of any local inflammation in the entire course of the disorder, and 
without any conclusive signs of its previous existence being re- 
vealed on examination after death. 

Some fevers from their commencement, present no symptom 
of gravity, and seem to proceed naturally towards a favourable 
termination. Others, from the invasion, or early in their progress, 
show that the organism is so much affected that cessation of the 
vital functions must necessarily result. The class of symptoms 
belonging to this condition are called typhoid, and are peculiarly- 
prominent in typhus, and constitute its essence, but may super- 
vene in the course of other varieties of fever. They are shown 
by a feeble, compressible pulse; by diminution in the secretions 
indicated in the dark, dry, and viscid coating of the tongue and 
mouth, the complete anorexia, and the dryness and even pun- 
gency of the skin; by the great implication of the nervous system, 
exhibited in dullness and confusion of intellect, excessive prostra- 
tion, involuntary muscular spasms, obtuseness of the senses, par- 
ticularly that of hearing, and the peculiar low muttering delirium 
in the advanced stages of the disease; the frequent presence of 
specific affections of the skin, characteristic of certain varietes of 
idiopathic fever; and finally the peculiar condition of the blood. 



IDIOPATHIC FEVER. 281 

with its decided tendency towards haemorrhages, petechias, and 
other signs of what was formerly called putridity. ' These typhoid 
symptoms when they supervene in the course of other or local 
disorders, always imply the action of some cause on the system, 
distinct from local inflammation. Another distinguishing cha- 
racter of idiopathic fever is the great tendency to spontaneous 
favourable termination. 

" In many cases the febrile symptoms return at regular inter- 
vals of 24, 48, or 72 hours; and subside completely after a cold 
and hot fit of some hours' duration, by a spontaneous sweating, 
— constituting the intermitting form of fever. In others there 
are equally distinct, but less perfect and less regular remissions 
of the symptoms, and the term applied is remittent fever. And 
in the remaining or continued form of idiopathic fever, although 
we can observe only slight and partial abatement of the symp- 
toms at different hours of the day, we very often observe com- 
plete recovery from the most urgent and distressing symptoms, 
taking place spontaneously at various periods of the disease,— 
sometimes, in the fever of this country, as early as the 7th or even 
the 5th day; sometimes not until the 30th, or even 40th day, most 
generally between the 10th and 20th; sometimes very rapidly, 
and with evacuations (whether at regular or irregular times) evi- 
dently resembling the sweating stage of intermittents; sometimes 
gradually, and without any such critical evacuations; but under 
very various treatment, — often without the use of remedies, — 
and always with less assistance from remedies, and with much 
less risk of subsequent organic disease, than where recovery takes 
place from an equally disordered state of the system, consequent 
on decided internal inflammation."* 

II. The causes of Idiopathic Fever are not of constant and 
universal operation, as are those of inflammation. They occur 
in certain localities, cease for a time, and recur under various cir- 
cumstances, (§§ 8S, 89, 90,) thus proving them to result from some 
local and temporary agency. And we have good reason to be- 
lieve that all idiopathic fevers either originate from malaria (§§ 82, 
83, 84, 85, 86,) or propagate themselves in part at least, and in 
certain circumstances by contagion (§§. 93, 94, 104), {Jilison.) We 
know that certain conditions are favourable to the development 
of the disease, and that those who are in constant communication 
with the sick are liable to be, and frequently are attacked. 

III. It has been stated that idiopathic fever may occur and 
proceed to a fatal termination with all the organs devoid of any 
appearance of disease. That the morbid changes most frequently 
met with in fever are to be regarded as its consequences rather 
than its causes, is rendered probable from many circumstances. 

• Alison's Outlines of Pathology, p. 394. 
24* 



282 PROXIMATE ELEMENTS OF DISEASE, 

In many cases the local appearances after death are to be as- 
cribed rather to congestion, than to decided inflammation; a state 
which corresponds with the ascertained condition of the blood 
hereafter to be described.* All the recognized concomitant in- 
flammations in fever are essentially modified by it. If an indi- 
vidual suffering from inflammation of the skin be attacked with 
fever, the appearance of the former will be altered, and if effusion 
have occurred, it will be suppressed. There is, moreover, no 
correspondence between the intensity of the constitutional symp- 
toms, and the amount of local disease; the disorder may have 
been very severe, and after death such slight marks of inflamma- 
tion may be detected, as by no means to justify the fatal event. 
The appearances of inflammation, after death, correspond often 
with symptoms developed just antecedent to death, and not refer- 
able to the earlier periods of the disease; the accession, and a con- 
siderable portion of its progress being entirely independent of them. 
The locality of inflammation in fever is variable, no one organ 
being constantly affected. Another evidence of want of identity 
between fever and inflammation is the result of certain methods 
of treatment. The usual amount of evacuation so useful in simple 
inflammation, when employed to combat local affections in fever, 
is usually borne less well; its effects are slight or null, or it is 
positively injurious. 

IV. The peculiar state of the blood often, though, perhaps, not 
uniformly observed in fever, is directly inverse to that which we 
have seen invariably to be present in inflammation, (§§ 205, 213, 
404.) According to "Andral, the fibrin in fever uncomplicated with 
inflammation never increases. It remains at the physiological 
standard, or diminishes, and that to a degree never met with in any 
other acute disease. The most common complication of conti- 
nued fever (that of inflammation of the intestinal mucous mem- 
brane and its glands) and the eruptions in the exanthemata, have 
no effect in increasing the fibrin. Every form and variety of 

* A frequent coincidence in fever is the diminution of the fibrin of the blood, 
and the facility with which congestion (so often confounded with genuine in- 
flammation) is produced. The circulating mass being deprived of its ordinary 
quantity of fibrin, the red corpuscles seem to lose at the same time the power of 
regulating their movements, and accumulate and stagnate in the capillaries. There 
is a peculiar congestion, which according to Andral is invariably connected with 
the typhoid state, whatever the disease may be. Its seat is the spleen, which 
becomes remarkable both from the increase in its volume, and the diminished 
consistence of the matter which fills its cells. Softening of the spleen in such 
cases is not due to any alteration of the tissue itself, for when by washing, the 
organ is empted of fluid, it is found natural. It is the contained matter which 
has lost its consistence, and this is coagulated blood, retained in the areolar 
tissue of the spleen. Like all blood poor in fibrin its coagulation is imperfect. 
The same condition of the blood in similar states is found in the clots in the heart 
and great vessels. Hence the enlargement and softening of the spleen which ac- 
companies all well-marked typhoid symptoms may be considered as the effect of 
the diminution of the fibrin of the blood.— {Hematologic Pathologique,-p. 71, 1843.) 






PATHOLOGY OF FEVER. 283 

fever, in every degree of intensity, will arise with every possible 
proportion in the globules. We never have the blood buffed in 
simple fever, in continued fever, variola, scarlatina or rubeola: 
( Andral). The specific cause which produces fever acts upon the 
blood in such a manner as to tend to destroy the coagulable prin- 
ciple. 

The Pathology of Fever. From what has been said we are 
entitled to assume that there is the strongest presumption for the 
belief, that what has been called Idiopathic fever is specifically 
distinct from local inflammation. The concurrent testimony of 
an examination into the phenomena of fever, shows that the 
description given many years ago, by Fordyce, is a correct one. 
"A fever is a disease which affects the whole system; it affects 
the head, the trunk of the body, and the extremities; it affects the 
circulation, the absorption, and nervous system; it affects the skin, 
muscular fibres, and the membranes; it affects the body, and 
affects likewise the mind. It is therefore a disease of the whole 
system, in every kind of sense. It does not, however, affect the 
various parts of the system uniformly and equally, but on the 
contrary, sometimes one part is much more affected, compared 
with the affection of another part. Sometimes those parts which 
Avere most affected at one time, are least affected at other times; 
so that the appearances which are the principal ones in one 
fever, are by much the slightest in another, or sometimes are 
totally absent." (Fordyce on Fever, 2d Amer. ed., p. 16, 1823.) 
From the nature of its cause, the agency of some poison, pro- 
bably sometimes engendered within the system, but most com 
monly derived from without, it is most probable that its influence 
is exerted on the system throughout. With regard to the mor 
bific cause which produces and maintains the peculiar characters 
of febrile phenomena, some important points are to be considered. 

" It may be questioned whether the effect on the nervous 
system, essential to fever, is produced directly by the external 
cause of fever, or whether that cause first works a change on 
the blood, and through its intervention affects the brain and 
nerves. 

" It is plain that the blood is changed, at least as to its power 
of coagulation, in most cases, and probably it may be so in all 
cases of idiopathic fever. But a similar change as to that pro- 
perty may be produced in it, by causes acting in the first instance 
on the nervous system; and this fact, therefore, does not indi- 
cate the |»art of the system which is primarily affected in fever. 

« Reasons which appear, on first consideration of the subject, 
satisfactory, may be given ;i lt;i ii ist the supposition of many of the 
older pathologists, that fever essentially and exclusively consists 
in a certain change in the blood (quae procsens morbum facit, 



284 PROXIMATE ELEMENTS OF DISEASE. 

sublata tollit, mutata mutat); in particular, two facts already- 
stated, viz. 1. That after the morbific cause has been applied to 
the blood, it may depend, as we believe, on causes acting on the 
nervous system only, whether or not it shall produce its specific 
effect; and, 2. That even after that specific effect has been pro- 
duced, and the febrile actions begun, they may, in a few instances, 
be arrested by means (such as the cold affusion) which neither 
evacuate any part of the blood, nor alter its composition. But 
when it is distinctly understood that the change in the blood, be- 
lieved to be morbific, is not in its chemical constitution simply, 
but in the vital qualities by which that constitution is constantly 
regulated and maintained, these facts have not the weight against 
the humoral pathology of fever, which has been ascribed to them. 

"At least it may be thought, that the remote cause of fever 
does not produce its effect by merely once impressing the ner- 
vous system, or other living solids; but that it must necessarily 
affect for a time the fluids of the body, and perhaps multiply itself 
in them, in order that it may take effect on the solids. And in 
favour of this form of the humoral pathology of fever, the fol- 
lowing facts may be stated. 

" 1. In a great majority of the cases in which we see typhoid 
fever, we are sure that some peculiar matter, generally absorbed 
from without, must be contained in the blood; as in the case of 
fever from malaria, from contagion (whether of simple fever or 
the eruptive fevers) from inflamed veins, from animal poisons 
introduced by wounds, or from suppression of the natural excre- 
tion at the kidneys. That this peculiar matter, or the blood 
altered by it, should act like a ferment, assimilating much of the 
circulating fluid to itself, in the former case equally as in the latter, 
is quite in accordance with what has been observed, when puru- 
lent matter has begun to form in the blood. (See Gulliver's Trans- 
lation of Gerber, p. 104.) 

" 2. In all cases of idiopathic fever, as well as of the eruptive 
fevers, an interval, which is variable and often long, necessarily 
elapses between the application of the morbific cause, and the 
development of the fever; which is easily understood on the sup- 
position that a change is gradually wrought on the blood during 
that interval, but not on the supposition of the poison acting sim- 
ply on the living solids. 

" 3. In a great majority of cases of typhoid fever, we know 
that a matter, similar in its effects on the human system to that 
which excited the disease, is ultimately evolved in large quantity 
from the blood, making the disease contagious; i. e. the morbific 
poison in one way or another is multiplied in the blood of the 
living body. 

" It has been naturally supposed by pathologists at different 
times, that the frequent and rapid abatement of fevers, after 



PATHOLOGY OF FEVER. 285 

critical evacuations, is farther proof of the doctrine of their cause 
residing chiefly in the blood; and that this morbific cause is really 
carried off by these evacuations. And in support of this opinion, 
it has been stated, that when putrid matters, or diseased secre- 
tions, have been injected into the veins of animals, and excited 
febrile symptoms, a peculiarly fetid diarrhoea has preceded the 
recovery from these. 

"But when it is considered, 1. That copious or spontaneous 
evacuations (e. g. of sweat) at the critical periods of fevers, often 
take place without the least good effect, if unattended by other 
marks of restoration of the natural condition of the capillaries; 2. 
That many fevers abate spontaneously and perfectly without 
crisis; 3. That in all contagious diseases, morbific effluvia escape 
for a long time from the body, without any good effect; 4. That 
there is no evidence of the critical evacuations possessing more 
contagious property than the effluvia which continually escape 
without advantage; and lastly, that in small-pox in particular, 
experience has shown, that the morbific matter in the pustules 
may be evacuated as quickly as it appears, without benefit, and 
may be reabsorbed into the blood without injury; — we must 
think it doubtful whether the critical evacuations are the cause 
of the solution of the fever that succeeds them, or whether we 
ought not rather to regard them as the sign of the restoration of 
the natural state of the vital actions in the capillaries of the body; 
whereby the excited action of the heart is enabled to throw off an 
unusual quantity of secretions and excretions, and then subsides; 
because the cause confining the circulation, and therefore stimu- 
lating the heart, has ceased to operate. 

" The doctrine of the existence of a morbific matter in the 
blood, therefore, is not established by the facts as to the critical 
evacuations, but must be rested on the other facts above stated." 
(Alison, pp. 438—441.) 

In whatever manner the circulation is affected in fever by the 
morbific agent, " it is to the direct action of this cause, and not 
to the influence of any local diseased actions, excited in the body, 
that we must ascribe the enfeebled state of the circulation — the 
altered state of the blood — the peculiarly vitiated state of the 
secretions — and in a great measure also, the deranged state of 
the nervous system which were described as characteristic of 
idiopathic and especially of typhoid fever." * 

It litis been suggested by a recent writer, (Alison,) that the 
morbific cause aftei existing for some time in the thuds, and per- 
haps multiplying itself, may act simultaneously on the constitu- 
tion of the blood, on the vital affinities in the capillary vessels, 
on the powers of the heart, and the vital action of the brain 

* Alison, p. 442. 



286 PROXIMATE ELEMENTS OP DISEASE. 

and nerves. The peculiar depressing influence of the morbific 
cause on the system generally, corresponds with those instances 
where the blood is undoubtedly altered, by the introduction of 
foreign matters either introduced from without or generated in 
the circulating fluid; as glanders, purulent infection, diabetes, 
granular kidney, &c. 

It must be borne in mind that certain concomitant local affections 
accompany certain cases of fever, or entire epidemics, or even 
very generally some species, complicating them materially, and 
increasing the danger. They may be divided into affections 
of the brain; affections of the chest; and affections of the abdominal 
viscera. 

Very generally the affection of the nervous system in fever is 
by no means simple inflammation, yet it is sometimes accompa- 
nied by that variety called sub-acute; at other times no morbid 
appearances will be found to correspond with the cerebral symp- 
toms during life. 

In the respiratory organs, the serous membrane is rarely in- 
volved, but the bronchial mucous membrane and the substance 
of the lung are liable to inflammation. The peculiar condensa- 
tion of the lower part of the lungs in the latter stage of fever is 
distinct from true hepatization. 

In the abdominal viscera the inflammation and subsequent 
ulceration of the mucous membrame and its glands, is perhaps 
the most common complication in this country in continued fever. 
The spleen, as before remarked, is enlarged, and apparently soft- 
ened. The stomach and liver, in some varieties of fever, and in 
hot countries, are frequently involved. 

There are three distinct fatal terminations in fever, owing to 
the depressing influence of the morbific cause on the circulation, 
in combination with the deranged condition of several vital 
organs, consequent on inflammation. "These are, 1. The death 
by Coma, referable partly to the peculiar action of the cause of 
fever on the brain, but partly also to increased determination of 
blood thither, or inflammatory action or effusion there; 2. The 
death by Asphyxia, referable partly to the enfeebled state of the 
circulation, and want of power in the heart to propel the blood 
through the lungs, but partly also to bronchitis or pneumonia. 
3. The death by mere Jlsthenia, referable partly to the delete- 
rious effect of the morbific cause on the circulation, but frequently 
also in part to various local inflammations, prolonging the febrile 
state; and especially to the inflammations and ulcerations in the 
mucous membrane of the intestines, which appear to have in 
this, as in other cases, a peculiar sedative, and what was formerly 
designated as a sympathetic, effect on the heart's actions."* 

* Alison, p. 444. 



TREATMENT OF FEVER. 287 



Treatment of Fever. 



Idiopathic fever runs a certain course, and as it appears, tends 
naturally to a favourable termination. We have no means by 
which we can cut fevers short, or materially abridge their course. 
Our treatment must be subservient and auxiliary. We must 
endeavour chiefly to protect the functions essential to life from 
serious injury; or, in the language of Cullen, " obviate the tendency 
to death." 

The patient must be placed under circumstances which will 
favour the decline of the disease, and he must be withdrawn from 
the influence of all causes which may aggravate the febrile state. 
" It is to be remembered," says Dr. Alison, " that when patients 
are placed in the circumstances above stated, a great majority of 
them, in most epidemics, especially if young, and previously 
healthy, will pass through the disease favourably without any 
farther treatment; and that powerful remedies, of any kind, may 
materially injure the course of the symptoms that is to be ex- 
pected; therefore, that we should see clearly before us, some 
change that is likely to be injurious, and that some remedy fitted 
to counteract it, — and should look forward, besides, to the effect to 
be expected from that remedy on the ulterior progress of the symp- 
toms, before determining on farther interference; excepting only 
by such placebos as may seem necessary for the satisfaction of 
patients or their friends." 

Any peculiarities of type in the prevailing epidemic are to be 
noticed and regarded. Local complications, the chief source of 
anxiety and danger, are to be carefully watched; it being always 
borne in mind that concomitant inflammations in the course of 
fever are, as was stated, materially modified by the primary 
disorder; that evacuants are, as a general rule, but illy tolerated, 
and their effects widely different from those resulting from their 
use in idiopathic inflammations of the same organs. The state 
of the circulation should be constantly regarded, and its indica- 
tions immediately attended to, in order to prevent fatal asthenia. 
In those epidemics where debility is a prominent feature this 
condition should be anticipated, and guarded against by appro- 
priate means. Mild nourishing food given frequently in small 
quantities, with the use of stimulants, constitute our chief reliance. 

The entrance on convalescense is one of the most, critical pe- 
riods in fever,and must be carefully watched, both from the tend- 
ency to relapse, from exposure, fatigue, or errors in diet, as well 
as the liability to the development of latent inflammations, par- 
ticularly of the chest. — C] 



CHAPTER IV. 



STRUCTURAL DISEASES OR DISEASES OF NUTRITION. 
ULTIMATE AND PROXIMATE ELEMENTS. 



SECTION I. 



NATURE AND CLASSIFICATION. 

521. Although we have had frequent occasion to advert to 
the changes in the process of textural nutrition effected by in- 
flammation, congestion, &c, and although nutrition might be 
included under the head of secretion, (§ 178,) a primary element, 
yet it has seemed better to defer the notice of diseases of nutrition 
until now; both because the previous consideration of disorders 
of the blood and its vessels gives the best introduction to them, 
and because we cannot strictly distinguish structural disease into 
ultimate and proximate elements. By analogy, indeed, we might 
infer that ultimate structural disease is that which affects element- 
ary structures singly, such as muscular fibre, nervous matter, 
cellular texture, &c; but we find structural disease rarely to be 
thus confined to one anatomical element, but rather to affect 
structures as they exist in more or less complexity. 

It will not be consistent with the plan of this work to give the 
details of structural disease, which belong rather to the depart- 
ment of morbid anatomy. It will be sufficient for our purpose 
to notice the chief forms of diseases of structure by tracing them 
through the alterations in the function of nutrition which pro- 
duce them. This method will enable us to class these diseases 
in a natural arrangement, and under each head to state briefly 
what is known with regard to their nature and origin, and the 
remedies which influence them. 

As in the case of functional diseases, so of structural lesions, 
which are modifications of the function of textural nutrition, they 
may be comprehended under the three heads, increased, dimi- 
nished, and perverted nutrition. 



ELEMENTS OF STRUCTURAL DISEASE. 



289 



ELEMENTS OF STRUCTURAL DISEASE. 



Tncreased=hypertrophy 
Diminished=atrophy 

Induration. 



SUTBITION 



^Perverted 



("Contraction 
Dilatation 
altered J Obstruction 
mechanism J Compression 
| Displacement 
^Rupture, &c. 



Softening. 

Transformation Cicatrices. 

EuplasUc £ Falsemembranes# 



Deposits* 



•D 



"Cirrhosis. 
l_ Atheroma, &c. 



L. Aplastic 



f Non- 
malignant 
^Growth s< 



^Malignant 



Yellow tubercle. 
Calcareous matter, 
&c. 

'Cysts. 
Tumours. 
Hydatids, &c. 

"Carcinoma. 
Encephaloma. 
Melanosis, &c. 

522. It is not possible to enter fully into the minute or micro- 
scopic nature of these different modifications of structure, for 
observation has not yet supplied sufficient facts for such a detail; 
a general view derived from the more obvious characters of 
structural diseases will suffice for our present purpose. It must 
be remembered that the division here given, simple as it is, is too 
precise to be rigidly applicable to many cases. Lesions of nutri- 
tion often graduate into each other, and are very commonly 
combined; hypertrophy of some textures frequently co-existing 
with atrophy of others, perverted nutrition being often combined 
with excessive or defective, and several of these different changes 
often occurring in succession in consequence of the operation of 
the same cause. We have already found this to be the result of 
inflammation, (§ 479;) and inasmuch as that process exaggerates 
the changes of nutrition, it has furnished us with many examples 
of the production of structural lesions. What we now have to 
notice, are those changes, which take place independently of dis- 
tinct inflammation, and which are mere modifications of that 
process of nutrition or reparation which is continually going on 
in the textures of the living body.* 

523. As in inflammation, so probably in the ordinary process 
of nutrition, the material of which the organized solids are formed 
is the fibrin of the blood. This, by the formation of nucleated 

• For the best summary of our present knowledge on the subject of nutrition 
sec Dr. Carpenter's "Human Physiology." 
25 



290 STRUCTURAL DISEASES. 

cell-germs, and fibres, constitutes the basis of textures, which are 
afterwards further modified by growth and multiplication, and by 
the deposition of homogeneous or hyaline matter in their in- 
terstices. Some structures are chiefly formed of the nucleated 
cells pressed together and consolidated in rows and layers, as in 
the epidermis and the epithelium of mucous membranes. In other 
textures, the cells elongate into fibres, as in cellular texture and 
its modifications, serous membranes, fibrous and tendinous struc- 
tures. In other textures, as cartilage and bone, the chief material 
is an amorphous solid deposit in an organized fibrous or cellular 
structure already formed. In the first formation and growth of 
textures, the production and multiplication of cell-germs from the 
plasma of the blood is necessary; and it is interesting to observe 
that in young animals, in pregnant females, and in the subjects of 
inflammation, the colourless corpuscles in the blood, (§ 212,) 
which probably are cell-germs, are much more numerous than 
usual, (§ 41S.) But in the ordinary textural nutrition of adult 
animals there is less need of the formation of new cell-germs; 
those already existing in the texture maintain the process by 
drawing nourishment from the blood-liquor, which furnishes the 
materials of all the solid textures; the formation of new cell-germs 
thus normally diminishes as age advances, and when then in- 
creased it is usually the result of disease. Nutrition in all its 
stages is essentially a vital process: the formation of cytoblasts or 
cell-germs, their growth into cells, their power of separation or 
secretion of certain matters from the blood-liquor, their power of 
reproduction, all are properties peculiar to living matter, and are 
to be regarded as ultimate facts or elements in physiology. When 
their laws shall have been more fully studied, we may hope to 
trace to these elements, varied in proportion and kind, correspond- 
ing elements in pathology, which will explain much that is at pre- 
sent obscure in the origin and nature of structural diseases. But 
we must now be content with a more superficial notice of these 
lesions. 

524. As nutrition depends on the blood for its material, and 
on the supply of arterial blood for the activity of the process, so 
it may be anticipated that changes of nutrition commonly arise 
from differences in the quantity and quality of the blood, and 
from variations in its arterial character. Hence diseases of nutri- 
tion are usually connected with diseases of the circulation and of 
the blood, (§269,) a moderately active circulation and a rich 
blood favouring nutrition; a poor blood (§ 260) and either too 
active or too feeble a circulation, impeding it; and a diseased 
quality or proportion in the elements of the blood (§ 186, 211) 
rendering it depraved. These causes operate on the whole 
frame; but they commonly affect some textures more readily 



INCREASED NUTRITION HYPERTROPHY. 291 

than others, because the process of nutrition is naturally more 
active, and therefore is more speedily influenced in some than in 
others. Thus fat and cellular textures are increased or diminished 
sooner than muscle, muscle sooner than tendon or bone, &c; and 
for similar reasons degenerations and other changes of structure 
affect some parts more than others, (§ 311.) But structural dis- 
eases are more commonly partial, from causes existing in the 
part; and no causes are more common than those which affect 
the circulation of the part, so that partial anaemia, congestion, 
determination of blood, and inflammation, are the most frequent 
causes of partial structural disease. We have made a similar 
remark of diseased secretion (§ 159) and other elements of dis- 
ease. If the nervous influence affects nutrition, it is probably 
through its operation on the circulation of the part. Thus a para- 
lyzed limb wastes because, not being exercised, it is not so freely 
supplied with blood. The muscles of the limb of a frog, the 
nerves of which are divided, lose their irritability and waste also; 
but Dr. John Reid has shown that by exercising these muscles 
by electricity, which promotes the circulation, both their irri- 
tability and nutrition are maintained. 



SECTION II. 

INCREASED NUTRITION. HYPERTROPHY. 

525. Hypertrophy, as a disease, is always partial; for although 
the whole body in cases of obesity acquires an enormous bulk, 
this is from the extraordinary growth of the adipose tissue, a 
part only of the frame. When the nutrition of textures generally 
has readied the acme of full health, there is no more increase, 
and the superfluous nutriment accumulates in the blood-vessels, 
causing plethora, (§ 27G.) Hypertrophy may affect individual 
textures, ox whole organs composed of many textures: in the 
former case, it may be called simple hypertrophy, (an ultimate 
element of structural disease;) and in the latter, complex hyper- 
trophy, (a proximate element.) Let us mention a few examples 
of each. 

526. Muscles become enlarged by full exercise alternated with 
sudi'i.iii repose, and a healthy condition of the blood. This in- 
creased development in the voluntary muscles generally cannot 
be called disease; but I have seen it occur in the sterno-chddo- 
mastoid muscle, long the seat of convulsive motion, and by giv- 
ing too L r iv;ii power lo the muscle, it seemed to perpetuate the 
distortion. The best cine lor this would Imve been Dieflenbach's 
operation for dividing the muscle, as in the case of squinting, in 



292 STRUCTURAL DISEASES. 

which certain muscles gain too much power and probably bulk. 
But muscular hypertrophy is chiefly morbid when it affects invo- 
luntary muscles. Thus, in the heart, it results from continued 
excitement in sthenic subjects; and from the violence with which 
the enlarged heart moves and propels the blood, it produces 
various bad effects. The muscular fibres of the bladder become 
hypertrophied in case of enlarged prostate, or other cause of diffi- 
cult micturition: those of the stomach are so from stricture of the 
pylorus; those of the bronchi are in chronic bronchitis, and dys- 
pnoea is the result. 

527. Hypertrophy of the interstitial cellular textures of the 
lungs, liver, &c, occurs after long-continued congestion from dis- 
ease of the heart, &c. (§311.) In the cellular texture of the lower 
extremities it appears to be a chief constituent of elephantiasis. 
Hypertrophy of the epidermis occurs in callosities of the skin, 
and corns, from continued irritation or pressure, which causes de- 
termination of blood to the part. Another form of hypertrophy 
of the cuticle is that arising from chronic inflammation in pso- 
riasis, chronic eczema, and impetigo. The cuticle is here retained, 
and from its stiffness it often cracks into chaps or rhagades. In 
the more temporary or more superficial cutaneous flushes, con- 
gestions or inflammations of erythema, scarlatina, lepra, and 
pityriasis, the superfluous epidermis is thrown off in a peeling of 
the skin, or in detached scales. But ichthyosis presents the most 
extraordinary instance of hypertrophy of the epidermis, its scales 
accumulating in a solid state, so as to form scales, or coarse bristle- 
like projections. These affections of the epidermis have their 
parallels in diseases of mucous membranes; but the secretions of 
these membranes being fluid, the nucleated cells, which on the 
skin would form solid scales, here are thrown off in the mucus, 
which presents an increased number of epithelium scales, as well 
as the exudation corpuscles and a viscid amorphous fluid, (§ 455.) 
Such disordered secretion of the mucous membranes not un- 
frequently coexists with cutaneous diseases; thus, bronchial con- 
gestion with viscid secretion occurs in persons affected with 
psoriasis and lepra. 

528. Complex or hypertrophy of organs of a healthy kind 
may result from a more copious flow of blood to them, contin- 
gent on their increased use. Thus, the uterus becomes hypertro- 
phied in pregnancy; the breasts during lactation ; one kidney 
becomes enlarged when its fellow is incapacitated by disease. 
The brain is more developed in proportion to the active exercise 
of the mind; and when this is carried too far, if inflammation, 
congestion, or some other vascular disorder, do not occur, the 
brain may become hypertrophied, and by its bulk being too great 
for its bony case, it compresses the vessels, becomes indurated, 



DEFECTIVE NUTRITION — ATROPHY. 293 

and, as an obvious consequence, its functions are more and more 
impaired. Thus, in young subjects who have been remarkable 
for precocity and activity of intellect, the brain has been over 
nourished, and fatuity and coma have been the result. Mucous 
and cutaneous follicles sometimes acquire an extraordinary de- 
velopment after continued excitement, or without any such 
obvious cause. Bursas become enlarged in situations exposed to 
much pressure or friction, as on the shoulders of porters, the knees 
of housemaids, the elbows of miners, and the ankles of tailors. 

The hypertrophy of the liver and spleen in protracted ague, 
may perhaps be referred to the frequent repetition and long con- 
tinuance of the enormous congestions which this disease induces 
in these organs. I have known a similar enlargement ensue after 
prolonged exposure to cold and wet. But in some cases no such 
external cause can be traced; and the hypertrophy must be re- 
ferred to a peculiar condition of the Circulation of the affected 
organs, or to an unusual activity in their nutrient molecules. To 
this obscure category may be appended the case of enlargement 
of the thyroid gland in bronchocele. 

529. The treatment of hypertrophy . must depend on the 
pathological cause which induces it. In most- cases, this cause 
is some variety of hyperemia, and the treatment suitable for the 
variety is to be employed, (see Congestion, Determination of 
blood, and Inflammation.) But some remedies seem especially 
calculated to counteract the hypertrophy which these elements 
induce; such are iodine and its preparations, mercury, alkalies, 
and, in the more sthenic cases, sedatives and evacuants, together 
with low diet. The same remedies are occasionally useful also 
in hypertrophy less distinctly connected with hypersemia, as 
bronchocele. In all cases it is proper to attempt, as much as 
possible, to remove or counteract the exciting causes of hyper- 
trophy, as by tranquillizing the circulation in hypertrophy of the 
heart; by soothing irritations of the stomach, bladder, &c, in 
obstructive diseases of these viscera; removal from malarious 
districts in case of visceral enlargements, &c. 



SECTION III. 

DIMINISHED NUTRITION ATROPHY. 

530. Atrophy, unlike hypertrophy, (§ 525,) may be a general 
disease; thai is, all parts of the body may waste so much as to 
impair their functions. General atrophy, marasmus, ox emacia- 
tion, consists in m removal of ;i considerable amount of the tex- 
tures by decay and absorption without a sufficient reparation by 
25* 



294 STRUCTURAL DISEASES. 

nutrition, (§ 523.) Hence the causes of atrophy may be divided 
into the circumstances which promote decay, and those which pre- 
vent reparatory nutrition. Among the former may be counted 
excessive and prolonged exertion, want of sleep, extreme anxiety 
of mind, or continued suffering; under any of these, a person is 
familiarly said to be "worn to a shadow," without any more 
distinct disease taking place. But On examining the urine in 
such cases, it will often be found to contain an excess of urea, 
resulting from the decay of textures. This secretion is also some- 
times alkaline, and unusually prone to decomposition, and the 
intestinal and cutaneous excretions sometimes exhibit an uncom- 
mon foetor, arising from the same tendency to putrescence. A 
fever of a low or hectic kind may be excited as a secondary re- 
sult of these changes, and this fever is mistaken for the cause of 
the wasting. In cases of marasmus from excessive secretions 
or drains from the body, there is often also proof of accelerated 
pecay: thus, diabetes mellitus reduces the body, not only by per- 
verting and draining off its nourishment, (§ 255,) but also by 
promoting the decay of textures which is manifest in the in- 
creased amount of urea excreted. 

The circumstances which impair or prevent reparatory nutri- 
tion are several, and may occur in any or all the steps of the nu- 
tritive process, from the reception of food into the system to its 
appropriation and assimilation to the living textures. As exam- 
ples in this series may be mentioned — 1. Defective quantity or 
innutritious quality of food; 2. Disorder of some part or parts of 
the digestive apparatus, such as extreme dyspepsia, diarrhoea, 
&c, which prevent the formation of chyle;. 3. Diseased mesenteric 
glands or tumours obstructing the thoracic duct, intercepting the 
supply of chyle to the blood; 4. Perversion of the assimilating 
process by which chyle is converted into blood, (§ 253,) as in 
diabetes mellitus and chylosus; 5. Defect in the formation of 
fibrin, (§ 196,) and albumen (§ 221) of the blood, the materials 
of nutrition, so that, instead of becoming the plastic material for 
repairing the texture, they have a tendency either to pass into 
decomposition, as in malignant fevers,* (§ 257.) or to concrete in 
a cacoplastic or aplastic form, as in tuberculous diseases; 6. Ex- 
cessive discharges of various animal fluids, of blood, pus, serum, 
milk, semen, mucus, &c, or morbid growths, which monopolize 
the nourishment of the body, such as tumours of various kinds, 
particularly cancer; 7. Parasitical creatures, such as hydatids, 
worms, &c. 

* My friend, Dr. Hodgkin, considers a suspension of textural nutrition to be a 
chief cause of the phenomena of fever, and has very ingeniously applied this no- 
tion to explain many of the symptoms. Lectures on Morbid Anatomy of Serous 
and Mucous Membranes, vol. ii. p. 490. 



DEFECTIVE NUTRITION — ATROPHY. 295 

531. A consideration of the above list of causes of emaciation 
will show how uncertain it is as a symptom if it be taken alone; 
but when traced to its cause, it is a very important index of the 
amount to which that cause operates on the living body. Ema- 
ciation will rarely continue or. advance to an extreme degree 
without structural changes rendering the cause permanent; hence, 
extreme marasmus is generally connected with tuberculous dis- 
ease, carcinoma, (especially of the stomach,) or some serious or- 
ganic disease. The chief exception to this is diabetes; the intract- 
able persistence of which is involved in much obscurity. 

532. Partial atrophy, the reverse of partial hypertrophy, com- 
monly arises from defective supply of blood to the part. Some- 
times the defective supply is from the disuse of the part: thus the 
eye wastes in confirmed blindness; muscles and whole limbs be- 
come atrophied from disuse in paralysis and anchylosis: the testicle 
and the mamma waste with age, &c. Frequently partial atrophy 
in an organ succeeds the changes induced by inflammation or 
other structural disease; the matter effused swells some parts, com- 
presses others of the- texture, and, by preventing a due supply of 
blood, causes a subsequent atrophy. This is especially the case 
when the products of inflammation or congestion are cacoplastic, 
as in cirrhosis of the liver and granular disease of the kidney, in 
the consolidation of the lung caused by pleuropneumonia, &c: 
the deposits here produced tend to contract and compress the 
vascular structure, and thus deprive the organ of its nourishment; 
it accordingly shrinks in size, or, in the case of the lungs, the tex- 
ture may become thin and emphysematous. In chronic pneu- 
monia and phthisis, also, many blood-vessels in- the lung become 
obliterated, and the texture may either waste or further degene- 
rate, according to its condition. Atrophy of the heart and brain 
have sometimes been found connected with ossification and par- 
tial obstruction of the arteries supplying them. The dwindling 
of limbs in children, and the lameness in old persons from shrink- 
ing of the neck of the thigh-bone, appear to depend on similar 
impediments in the vessels supplying the parts. 

533. The treatment of general atrophy (§ 530) must be di- 
' rected to remove or obviate the cause where that is practicable, 

to supply proper and adequate nourishment, and to promote the 
healthy action of the digestive, assimilatory, and circulatory 
functions. The means of fulfilling these indications, where attain- 
able, would require too lengthened a detail to be introduced here: 
it must suffice to mention the chief remedies and measures to be 
opposed to the several pathological causes of atrophy. 

Atrophy, from excessive or prolonged exertion, is to be treated 
by a sumcienl amount of rest and nourishment} thai from anxiety 
of mind, suffering, or sleeplessness, by various medicinal nar- 



296 STRUCTURAL DISEASES. 

cotics, and change of air and scene, as well as by measures cal- 
culated to soothe under the particular circumstances. The effect 
which opiates and other narcotics sometimes have in diminishing 
the urea excreted in such cases, points out that these remedies 
tend to control decay, and they may sometimes be aided by min- 
eral acids and various tonics. The same remedies are useful in 
diabetes mellitus, the marasmus of which is however to be still 
further checked by withdrawing all articles of food that can be 
converted into sugar — that is, all farinaceous, amylaceous, sac- 
charine, and gelatinous matters, (§256.) I have generally found 
the excessive discharge and the emaciation of diabetes to be 
effectually controlled by the full application of this rule, but never 
by its partial observance', as recommended by Dr. Prout. 

The counteraction of the circumstances which impair or pre- 
vent reparatory nutrition (§ 530) comprise the treatment of the 
several diseases and causes of disease before enumerated under 
the seven heads, which it is not necessary to recapitulate. In 
most of these the use of food as nourishing as the stomach can 
digest, and of tonics, medicinal and hygienic, as bracing as the 
body can bear, with due attention to the regularity of the excre- 
tions, afford the best chance of resisting or retarding the emacia- 
tion; and their utility will much depend on the judgment with 
which they are applied. 

534. As partial atrophy often arises from defective circulation 
in a part, it may sometimes be counteracted by measures calcu- 
lated to promote the passage of blood through that part. Thus, 
muscles wasted by disuse are sometimes increased and strength- 
ened by blisters, stimulant frictions, electricity, and exercise. 
Atrophy following inflammation or congestion may sometimes be 
advantageously opposed by the remedies for the results of these 
conditions, especially iodine in combination with tonics, as iodide 
of potassium and sarza, iodide of iron, &c. In this and most 
other cases of structural disease, although treatment can do little 
to remove partial atrophy already induced, yet it may sometimes 
retard its increase by restoring a more healthy circulation through- 
out the body. 

PERVERTED NUTRITION. 

535. Under this head are comprehended all those changes of 
textural nutrition that go beyond mere degrees of plus and minus 
hi the natural molecules of the textures; they either alter the 
quality of the texture, or form new textures, growths, or depo- 
sits, in connection with the normal texture. These changes often 
comprise partial hypertrophy and atrophy as well; and in so far 
as they do so, the observations already made with regard to those 



PERVERTED NUTRITION INDURATION AND SOFTENING. 297 

elementary changes may be extended to these, but with new 
additions. 

SECTION IV. 

INDURATION AND SOFTENING. 

536. We have mentioned both induration and softening to 
occur as the results of inflammation; softening being commonly 
connected with the increased secretion and absorption occurring 
in acute inflammation, (§ 427;) and induration being rather a 
sequel of the more chronic kind, which causes a continued over- 
flow of the solid nutritive matter, (§ 479.) Both these changes 
sometimes take place independently of complete inflammation; 
but they probably, in most cases, depend on some of its elements. 

537. Induration is constituted by an increased deposit of solid 
matter in a structure, or by compression of that structure, or by 
both. In some cases of insanity, the inner table of the skull 
acquires the hardness of ivory. Iii newly-born children, the skin 
acquires an unusual hardness and rigidity, rendering them " skin- 
bound." Glands and other soft compound structures sometimes 
become hard without inflammation. Probably, in all these cases, 
there is prolonged determination of blood to the parts, which 
causes an exaggeration of the nutritive function; but the matter 
exuded is more hyaline, (§ 523,) or simply granular, (§ 452, 3,) 
than consisting of highly organized cell-germs or fibres; hence 
the result is not simple hypertrophy or increased growth, but a 
more condensed and more uniform texture. A somewhat similar 
change is produced in the lung by compression, by liquid effu- 
sion, or a solid tumour, especially when the lung itself is also 
inflamed, as in pleuro-pneumonia, in which the pressure restrains 
the full development of the exudation corpuscles. The indura- 
tion of cartilage, &c. by osseous deposit is more properly trans- 
formation than simple induration. So induration of the liver, 
kidneys, and other organs, generally comprise granular deposits, 
and other changes of structure. 

538. Softening arises from different causes in different textures. 
In some instances the cause, being peculiar to the structure, may 
be called specific. Thus in the bones it proceeds from defective 
deposition of phosphate of lime, the earthy .matter which gives 
solidity to these structures. The softening of the stomach found 
after death is caused by the solvent action of the gastric juice. 
Tin- soli cuing of various textures, especially muscles, in fevers 
;niil other cachectic Mates, is connected with a defect of fibrin in 
the blood, (§ L96:) the same cause which removes this fibrin, and 
prevents its formation, (§ 2 1G,) apparently dissolving or loosening 



298 STRUCTURAL DISEASES. 

the fibrinous parts of solid textures. In other instances, soften- 
ing is a variety of atrophy, arising from a defective supply of 
blood; so that the texture of a part decays, and is absorbed away 
faster than it is repaired. Thus softening of the brain and heart 
is sometimes found connected with ossification and partial ob- 
struction of the arteries supplying these parts. Softening of the 
affected muscles sometimes accompanies paralysis, especially that 
from lead. In a few instances, partial sofening, like atrophy, fol- 
lows inflammation, and is to be ascribed to the obstruction of 
vessels which that affection has produced. Thus softening of 
portions of the brain occasionally follows meningitis, softening 
of the heart succeeds to pericarditis; softening of the stomach 
and intestines occurs after some kinds of gastro-enteritis; soften- 
ing of the articular cartilages sometimes succeeds to their inflam- 
mation. 

In all cases of partial softening, although the chief cause is 
local, yet a nonfibrinous or aplastic condition of the blood mate- 
rially assists in promoting this result; and it is a serious question 
whether the continuance of antiphlogistic measures and absti- 
nence does not occasionally promote this consequence of the 
changes of inflammation. Some of the most distinct cases of 
softening of the heart and brain that I have met with, have been 
those in which the patients have been long kept in a reduced state 
for fear of return of inflammation of the heart and head. 

539. Induration and softening being opposites of each other, 
although sometimes preceded by similar causes, require in some 
degree parallel modes of treatment, but in an opposite way. 
Induration, consisting of condensed hypertrophy, and often aris- 
ing from prolonged determination, may be counteracted by par- 
tial antiphlogistic measures, especially those tending to remove 
obstructions and deposits, (§ 511, 515.) Thus mercury and 
iodine, externally and internally used, and alkaline saline medi- 
cines, are supposed to have some power in discussing hard 
swellings; and setons, issues, or suppurating counter-irritants, 
which draw away blood and nutriment from the indurated part, 
may be found in some cases useful. But extreme antiphlogistic 
or reducing measures are not indicated, (§218,) inasmuch as in- 
duration itself implies a degraded kind of the nutritive material, 
(§ 537,) and does not result from acute or sthenic inflammation. 

540. In cases of softening that are not specific, (§ 538,) the in- 
dications of treatment are, to restore a more fibrinous or plastic 
state of the blood generally, and to improve the circulation in the 
atrophied part. In fevers and cachectic states, where the soften- 
ing is general, the first is the chief indication, and some of the 
means of fulfilling it have been already noticed, (§ 216.) Besides 
nourishing food, and agents winch improve the digestion and cir- 



TRANSFORMATION OF TEXTURES. 299 

dilation, tonics and stimulants are often useful. How far the 
operation of mineral acids, bark, and other tonics, depends on 
their astringent or bracing influence on the animal fibre, we can- 
not undertake to determine; but after fevers, and in cachectic 
states, they do appear to improve the substance and firmness 
of the solids in a way more direct than by merely exciting the 
circulation and ameliorating the condition of the digestive organs. 
So, too, the operation of stimulants, both local and general, pro- 
bably goes beyond that of accelerating the circulation, and deter- 
mining blood to parts where it is ill supplied: it probably also 
increases the production of fibrin and cell-germs from the albu- 
men of the blood, just as we see this to result from the application 
of stimulants before they cause inflammation, (§ 294, 415.) The 
relief sometimes afforded to the symptoms of softening of the brain 
and heart, after all inflammation has ceased, by mild stimulants, 
tonics, and a moderately nourishing diet, is too little known to 
those who have always the dread of inflammation before their 
eyes, and who yet forget that a chief evil of inflammation is the 
injury it inflicts on function and structure, which injury often lasts 
when the inflammation is gone or is of trivial amount. The bene- 
ficial effect of nourishing diet and stimulant applications to soft, 
flabby ulcers, is another illustration in favour of this kind of treat- 
ment in cases of internal disease, where the general weakness, 
apyrexia, pallidity, and muscular emaciation, much preponderate 
over the symptoms of local irritation. 

541. The treatment of the specific example of softening found 
in the bones is not well understood. The circumstances which 
promote or impede the deposition of phosphate of lime in the 
bones are not clearly known; but measures of a tonic kind, with 
appropriate nourishing diet, have been found distinctly useful in 
rickets in children. The mollities ossium of adults is a still more 
obscure and intractable affection. The formation of callus at the 
ends of a fractured bone, and the completion of the ossific pro- 
cess in it, are promoted by generous diet and tonics. 



SECTION V. 

TRANSFORMATION OF TEXTURES. 

542. When one elementary texture, as muscle, is replaced by 
another, as fibro-cellular, it is said to be transformed. The term 
degeneration is also generally applicable to this change; for the 
now texture substituted for the old is most commonly lower in 
vital properties. The chief exceptions are in the case of skin 
being transformed into mucous membrane, when by anchylosis 



300 STRUCTURAL DISEASES. 

of a joint, an external surface is brought almost to the condition 
of an internal; and the converse case of transformation of mu- 
cous membrane into skin, as in long prolapsed uterus. In these 
instances, the changes appear to arise from the physical condition 
in which the membrane is placed: the exudation corpuscles re- 
maining soft and moist, and becoming epithelium scales and 
mucous globules in one case, and drying into epidermis in the 
other. 

543. Muscle is sometimes transformed into fibrous or fibro- 
cellular texture, in some cases after inflammation of contiguous 
parts. This has been noticed in the heart after pericarditis and 
endocarditis, in the intercostal muscles after chronic pleurisy, 
and in some of the muscles of the limbs after prolonged rheuma- 
tism. Loss of substance in muscles from wounds or ulcers is 
generally replaced by a similar fibro-cellular texture, and never 
by new muscle. 

Muscle has rarely been found degenerated into a fatty matter, 
the proper muscular fibre being replaced by a greasy homoge- 
neous structure. This has been observed under circumstances 
similar to those attending fibrous degeneration. Something of 
the same kind takes place sometimes in the muscles of persons 
long affected with sea-scurvy. Natural fat sometimes infringes 
on muscles, particularly the heart; but that is by the hypertrophy 
of the fat-cells pressing on and causing atrophy of the muscular 
fibres, and not by transformation. The same abnormal growth 
of fat is not uncommonly met with in the pelvis and calices of 
the kidneys. The fibrous transformation of muscle seems to be 
simply the result of a degradation of the nutritive process, fibrous 
texture being obviously less endowed with vitality than muscle. 
According to Mr. Gulliver, the opaque patches in arteries called 
atheromatous consist of a fatty deposit. The fatty degeneration 
of textures is involved in more obscurity; but it may receive 
some illustration from the spontaneous conversion into adipocire 
which this and other animal substances undergo in the course of 
time, when kept moist, yet prevented from rapid decomposition. 
The considerable proportion of oil globules found in some exuda- 
tion corpuscles by Gulliver, Gruby, and others, would also seem 
to point out that fatty matter may result from a modification of 
the nutritive secretion. Nay, according to the examination of 
Dr. Davy, exudation corpuscles (in the lungs at least) chiefly con- 
sist of margarine and olein.* But this does not accord with the 
account of fibrinous exudations generally given by chemists. 
The whole subject requires a fuller examination. 

Fatty degeneration of the liver admits of easier interpretation; 

* Mr. Gulliver's Notes to Dr. Boyd's " Vital Statistics," p. 53. 



TRANSFORMATION OP TEXTURES. 301 

for, according to Mr. Bowman, the natural secernent structure of 
this gland contains a considerable proportion of fatty particles; 
and the excessive increase of these, with atrophy of the other 
structures, may constitute the fatty transformation.* It has been 
surmised that this fat is that of the bile in the process of its form- 
ation in the secreting cells; and that its increase in phthisis is 
due to the additional task thrown on the liver to excrete the 
hydro-carbon, which the lungs cannot remove. If this were true, 
fatty degeneration of the liver should occur more constantly in 
phthisis, and in other diseases of the lungs, than it does. It is 
met with chiefly in females, in whom emaciation has proceeded 
with rapidity; and I should rather ascribe it to the arrest of the 
fatty matter from the blood, which is taken up from the textures 
in their rapid decay, and of which the liver appears to be the 
appropriate excreting organ. It is also possible that the fatty 
matter which is formed in tubercle during its process of soften- 
ing may be conveyed into the circulation, and contribute to the 
greasy degeneration of the liver. 

544. The most common transformation is that of cartilage into 
bone. This commonly takes place as a result of age, and may be 
said to be rather a petrifaction than an ossification; for the proper 
structure of bone is wanting. The deposition of osseous matter, 
however, seems to follow the same rule as in true bone, in which 
it increases with age. So, too, morbid ossifications result from 
inflammation or continued determination of blood, as instanced 
in the ossification of the cartilages of the air-tubes in chronic 
laryngitis and bronchitis, of the cartilages of the ribs in chronic 
pleurisy, and of the inter-vertebral cartilages after injuries of the 
spine. Thus inflammation, or rather the determination of blood 
which accompanies it, hastens the process of ossification to which 
cartilages tend in the lapse of years. 

A similar tendency to ossification (or rather petrifaction, for 
there is still less of the true bony structure than in the last case) 
is observed hi cartilage, fibrocartilage, and fibrocellular texture, 
accidentally produced by inflammation, (§ 452,) transformation, 
(§ 542,) or morbid growths. Thus, osseous concretions or laminae 
are formed on serous and fibrous membranes, in cellular texture, 
and in the accidental cartilages found in joints. This appears 
also to be the mode in which ossification of arteries and the 
valves and membranes of the heart takes place: an opaque fibro- 
cellulai deposit first occurs, and phosphate of lime afterwards 
concretes in plates or granules in it. The p history and calcareous 



• In the most authentic accounts of cases of spontaneous combustion of the 
human body, there are some particulars which seem to imply that there must 
have been a fatty transmutation of textures. 
26 



302 STRUCTURAL DISEASES. 

transformation of tubercle is obviously allied to the same process, 
and by proving that it takes place in aplastic and comparatively 
dead matter, seems to prove that osseous deposit is a chemical 
rather than a vital change. The similar changes sometimes ex- 
hibited in the cartilaginous bodies loose in veins (phebolites) and 
in the cavities of joints equally show that the transformation is 
spontaneous. 

545. Our knowledge of the nature and symptoms of transforma- 
tions is not sufficiently definite to suggest any observations with 
regard to their treatment. The general fact that they are examples 
of degeneration or degradation of vital properties, would indicate 
the propriety of employing measures for supporting the vital 
powers generally; but inasmuch as local inflammation or deter- 
mination of blood sometimes seems to hasten these changes by 
supplying the material, topical measures against these elements 
may sometimes be useful. 



SECTION VI. 

DEPOSITS IN OR UPON TEXTURES. 

546. I apply the term deposits to matters which result from 
an overflow of the nutritive material beyond what is necessary 
to nourish the textures themselves. The structural lesions hitherto 
considered are alterations of the textures themselves; deposits are 
new matters added to the textures. The basis of all deposits is 
the fibrinous matter of the blood; and in the products of inflam- 
mation (§ 450 — 3) we have described its varieties in relation to 
its plasticity or capability of organization. The same division is 
applicable to deposits, which take place independently of inflam- 
mation, as results of an overflow of the material of reparatory 
nutrition, and thus we have euplastic, cacoplastic, and aplastic 
deposits from perverted nutrition. The history already given of 
these as they result from inflammation will supersede the neces- 
sity of much detail now, and it will suffice to advert to the circum- 
stances in which they arise independently of inflammation. 

Euplastic Deposits — Cicatrices. 

547. When a living part is cut or wounded, the breach may 
be repaired by three modes: — 1. By the growth of the adjoining 
parts, or walls, of the wound; 2. by the medium of coagulable 
lymph, which becomes organized and forms a cicatrix, or bond of 
union; and 3. by granulations and lymph together. The latter 
mode being necessarily attended with inflammation, is excluded 



DEPOSITS EUPLASTIC CICATRICES. 303 

from notice here; but the other two, as Dr. Macartney has shown, 
may occur independently of obvious inflammation, and are more 
perfect without it. To these, however, a certain amount of de- 
termination of blood, which supplies the plastic material, is neces- 
sary; and premising this addition, I will quote the clear descrip- 
tion which Dr. Carpenter has given of these reparative processes. 
(Principles of Human Physiology, Am. ed., p. 440.) 

"The surgeon has, until recently, regarded the processes of 
granulation and suppuration, which are attended with much local 
inflammation and with a considerable amount of constitutional 
disturbance when the surface is large, as the only means by which 
an open wound can be filled up. Occasional instances, however, 
have not been wanting in which large open wounds have closed 
up under the dry clot of blood by which they were at first covered 
over, without any suppuration or other symptom of inflammation; 
and in these it has been found that the new surface much more 
nearly resembles the ordinary one than does the cicatrix which 
follows granulation. To Dr. Macartney, however, is due the 
merit of explaining the rationale of this action, which is precisely 
analogous to that which is concerned in the ordinary processes 
of growth, and to that reproduction of whole parts which takes 
place in the lower animals without inflammation.* It is termed 
by him the modelling process; and he remarks, as characteristic 
of it, that when it goes on perfectly and without- inflammation, 
the patients are so completely free from uneasy sensations as 
only to be aware of the extent of the injury by their own exami- 
nation. In this process the surfaces of the wound do not unite 
by vascular connection even when they lie in contact, nor is the 
space between them filled up with coagulable lymph; but they 
are smooth and red, moistened with a fluid, and presenting the 
appearance of one of the natural mucous membranes. " It might 
be anticipated that as this mode of reparation bears so strong a 
resemblance to the natural formation and development of parts, it 
is the slowest mode; but this is of little account when compared 
with its great advantages in being unattended with pain, inflam- 
mation, and constitutional sympathy, and leaving behind it the 

* The following observation illustrates this point: — "I made a small pin-hole 
in a frog's web; the capillaries that were divided yielded no blood, and became 
obstructed; but the circulation continued, although sluggishly, in those adjoining, 
Which were distant from the puncture the length of six or eight blood-disks. The 
'■Is were no nearer; but the circulation in them was more 
active, and the hole was partly filled up; and mi (he third 'lay, it was completely 
so, yet ttO moving blood could be seen nearer to it. On the fifth day, the distri- 
bution nf visible vessels was not altered, but the matter with which the hole was 
filled bad contracted and become opaque, so thai the adjoining vessels were 
drawn nearer together, and \\v opacity prevented my seeing whether any passed 
through the cicatrix."— Galstonian Lectures, Med. Gaz., July 80, 1841, p. 721. 



304 STRUCTURAL DISEASES. 

best description of cicatrix." In the case of large burns on the 
trunk of children, the difference between the two modes of repa- 
ration will frequently be that of life and death, for it often hap- 
pens that the patient sinks under the great constitutional disturb- 
ances occasioned by a large suppurating surface, although he has 
survived the immediate shock of the injury. 

548. " The most effectual means of promotiug this kind of 
reparative process, and of preventing the interference of inflam- 
mation, vary according to the nature of the injury. The exclu- 
sion of air from the surface, and the regulation of the temperature, 
appear the two points of chief importance. By Dr. Macartney, 
the constant application of moisture is also insisted on.* He 
states that the immediate effects of injuries, especially of such as act 
severely on the sentient extremities of the nerves, are best abated 
by the action of < sjeam at a high but comfortable temperature, 
the influence of which is gently stimulant, and at the same time 
extremely soothing, [promoting determination of blood without 
inflammation. — C. J. 13. W.] After the pain and sense of injury 
have passed away, the steam, at a low temperature, may be con- 
tinued;' and, according to Dr. M., no local application can compete 
with this, when the inflammation is of an active character. For 
subsequently restraining this, however, so as to promote the simple 
reparative process, water-dressing will, he considers, answer suf- 
ficiently well, its principal object being the constant production 
of a moderate degree of cold, which diminishes, whilst it does not 
extinguish, sensibility and vascular irritation, and allows the 
reparative process to be carried on as in the inferior tribes of ani- 
mals. The reduction of the heat in an extreme degree, as by the 
application of ice or iced water, is not here called for, and would 
be positively injurious; since it not only renders the existence of 
inflammation in the part impossible, but being a direct sedative 
to all vital actions, suspends also the process of reparation. The 
efficacy of water-dressing in injuries of the severest character, and 
in those which are likely to be attended with violent inflamma- 
tion, (especially Avounds of the large joints,) has now been estab- 
lished beyond all question, and its employment is continually 
becoming more general. Other plans have been proposed, how- 
ever, which seem in particular cases to be equally effectual. To 
Dr. Greenhow, of Newcastle, for instance, it was accidentally 
suggested a few years since,t to cover the surface of recent bums 
with liquefied resinous ointment, (consolidating as it cools;) and 
he states that in this manner suppuration may be prevented, even 
where large sloughs are formed, the hollow being gradually filled 
up with new tissue, which is so like that which has been detroyed, 

* Treatise on Inflammation, p. 178. f Med. Gaz., Oct. 13, 1838. 



DEPOSITS — BVPLA STIC — CICATRICES. 305 

that no change in the surface manifests itself, and none of that 
contraction which ordinarily occurs, even under the best manage- 
ment, subsequently takes place. A plan has moreover been pro- 
posed for preventing suppuration and promoting reparation by 
the modelling process, which consists in the application of warm 
dry air to the wounded surface. The experiments made on this 
have not been entirely satisfactory; but they seem to show that, 
although the process of healing is much slower under treatment 
of this kind, it is attended with much less constitutional disturb - 
ance than is unavoidable under the ordinary method." 

549. The other mode of reparation is that long denominated 
by surgeons union by the first intention, in which the sides of a 
wound heal by the organization of coagulable lymph, or more 
rarely of a clot of blood, which, when complete, forms a cicatrix. 
" This mode of union is ordinarily considered by British surgeons 
to be the result of an adhesive inflammation. In so regarding 
it, they conceive that they are following out the views of Hunter; 
but he expressly states that wounds may heal without any pain 
or constitutional disturbance, the re-union proceeding ' as if 
nothing had happened;' so that he in effect admits that reparation 
of this kind may take place without . inflammation. It is well 
known that if a slight wound which is thus healing be provoked 
to an increased degree of inflammation, its progress is interrupted, 
and all the means which the surgeon employs to promote union 
are such as tend to prevent the accession of this state. The 
doctrine that the effusion of lymph for the reparation of the tis- 
sues is not to be regarded as necessarily a result of the inflamma- 
tory process is not so novel as its opponents have regarded it, 
since it has been maintained by many eminent observers, even 
from the earliest times. It is supported by the fact that coagulable 
lymph may be thrown out by a natural and healthy action* as in 
the formation of the decidua uteri, and that the surface of a 
wound is covered with lymph too soon after the receipt of an in- 
jury for inflammation to have set in.* The only case in which 
the occurrence of inflammation can be regarded as salutary, is 
that hi which there is a deficiency of fibrin in the blood causing 

• Although I admit that inflammation in its pronounced form is not essential 
to this reparatory process, yet I cannot allow that this statement is altogether 
correct. It' inflammation is essentially what we have defined it, (§ 410,) an in- 
crease of lilmiil in a part, with the motion of that blood partly increased and partly 
diminished, it may commence a few minutes after a wound has been made. 
When ;i Grog's web is cut or pricked, the vessels adjoining the wound are imme- 
diately < .1 . -. 1 1 1 u- !. •« 1 liy roagulalnl Mood; Imt in ;l l'r w si'ci mils, those ;ui joining 

them bee ime enlarged, and receive an increased current, and it is mis determi- 
nation of blood towards vessels which are obstructed v. bich causes an increased 
transudation ol the, plasma of the blood, (§ 419.) If this do not amount to in- 
flammation, it (lifl'crs from it only in de 



306 STRUCTURAL DISEASES. 

a deficient .organizability of the lymph," (or rather a deficiency 
of lymph itself.) " It has been seen (§ 43S) that the amount of 
fibrin is rapidly increased by inflammation; and the surgeon well 
knows that a wound with pale flabby edges, in a depressed state 
of the system, will not heal until some degree of inflammation 
has commenced. ' 

550. " When the liquor sanguinis, known as coagulable lymph, 
is effused' between the two edges of a wound, or upon the sur- 
face of a membrane lining a closed sac, the following appears to 
be the history of its organization. The new matter which is 
poured out in a fluid state undergoes a coagulation resembling 
that of the blood; the serum, being set free by the concretion of 
the fibrin, is absorbed; and the fibrinous coagulum speedily 
attains an almost membranous density. If examined with a 
microscope at the commencement of the process of organization, 
it is seen to contain a large number of the exudation corpuscles, 
(§424;) these originating, probably, either in the lymph globules 
that have circulated in the blood, or in the nuclei of the red cor- 
puscles. In a short time these corpuscles present the appearance 
of regular cells disposed in layers, and adhering together by an 
intermediate unorganized substance, bearing in fact, a strong re- 
semblance to the cells of tesselated epithelium. Some hours 
later,* the mass exhibits an evidently fibrous character; and this 
is due (?) to the adhesion of the cells to each other in lines, their 
form being prolonged in the same direction. Between these cel- 
lular fibres a considerable amount of the cytoblastema Or hyaline 
substance (§ 523) yet remains, and they maybe readily separated 
or torn in any direction. A vascular rete next makes its appear- 
ance, and forms connections with the vessels ofthe subjacent sur- 
face; the first appearance of this network is in the form of trans- 
parent arborescent streaks, which push out extensions on all sides; 
these encounter one another, and form a complete series of capil- 
lary reticulations, the distribution of which very nearly resembles 
that which has been seen in the villi of the intestines. Before 
the vascular rete appears, pale-coloured cytoblasts are produced, 
which, after the completion ofthe rete, pass over into the nearest 
capillary veins, being pushed on by the blood which is brought 
from the nearest arteries, (§451;) and in this manner the circu- 
lation is established. This process appears to be conformable in 
all essential particulars with that which has been observed in the 
development of the toes of the larva of the waternewt and similar 
growths. The character, whether arterial or venous, which each 

* In this description, Dr. Carpenter seems to have chiefly followed the account 
of Gerber: but Messrs. Addison and Gulliver have shown that the formation of 
fibres takes place at first, and constitutes the chief part ofthe coagulation ofthe 
' fibrin. 



DEPOSITS — CACOPLASTIC AND APLASTIC. 307 

tube is to assume, depends upon its proximity with some vessel 
of the subjacent membrane, with which it becomes continuous; 
but its first formation is not due, as some have supposed, to the 
simple prolongation of these vessels into the fibrinous mass, 
since the latter is able of itself to originate a capillary plexus." 

551. Under some circumstances the fibrin of coagulable blood 
has been -found to become vascular, and more or less organized. 
Thus, clots of blood in the blood-vessels have been injected, and 
those effused in the brain in apoplexy have been found pervaded 
with vessels, (Cruveilhier;) but the colouring matter does not ap- 
pear to assist in the process: in fact, blood coagulated in or upon 
a wound generally comes off in a scab as soon as the wound is 
healed. In other instances, the presence of colouring matter 
seems to retard or degrade rather • than assist the plastic process, 
(§454.) 

552. The remedial measures by which the euplastic process is 
promoted in cases of injury are treated of in surgical works. 
Their object is to promote such an amount of determination of 
blood, (whether this be called inflammation or not,) and such a 
plastic condition of the blood, as shall contribute to the effusion 
of a. sufficient amount of healthy organizable lymph. Where in- 
flammation rises too high, it causes too much effusion of the 
plasma, which degenerates into aplastic pus globules, and it de- 
stroys the adjoining textures: here it must be repressed by anti- 
phlogistic measures. If the inflammation is too low, (§ 477,) or 
the determination of blood is wanting, then the plasma will be 
defective in quantity or organizability,'and the wound will not 
heal, or will heal imperfectly. Here stimulant applications may 
be useful. Where the blood is too abundant in fibrin, the plasma 
thrown out will be too copious to admit of organization, and will 
consequently become purulent, and therefore aplastic. Here, 
blood-letting or evacuants, and low diet for a time, may be ser- 
viceable. Where the blood is deficient in fibrin, the wound will 
be flabby and the discharge ichorous or sanious, from want of the 
proper plasma: here, nourishing diet, tonics, and even stimulants, 
general and local, may be useful. Where the wound exhibits 
congestion more than determination of blood, and the plasma is 
organized into loose spongy or fungous masses projecting from 
iln: wound, astringent and stimulant applications are beneficial. 

Cacoplastic and aplastic deposits. 

553. Under various circumstances which have been alluded to 
in the preceding remarks, wounds or ulcers may be repaired by 
lymph which is cacoplastic or defective in organizability; and the 
cicatrix resulting from such imperfect reparation is lower in the 



308 STRUCTURAL DISEASES. 

scale of vitality than the texture in which it is produced. . Thus 
in the skin, a tough, hard, flbro-cellular structure, constitutes the 
cicatrix; the seams formed on the healing of scrofulous sores 
sometimes exhibit this character; the blood not supplying a good 
plastic material. Or sometimes the cause of the degraded or- 
ganization seems to be in the nature of the wound, or in a modi- 
fication of the vessels of the part, or of their exudation, as in the 
scars which result from burns and scalds, and from some poi- 
soned wounds. In these cases, the cicatrix is dense and thick; 
and tends further to contraction, which causes a puckering of the 
parts, and sometirhes great distortion of the integuments. Similar 
deposits have been noticed to result from chronic and scrofu- 
lous inflammation of internal parts, (§ 479, 485,) and from con- 
gestion, (§ 311,) and to constitute the material of dense fibro- 
cellular and fibro-cartilaginous formations on and under serous 
and in cellular membranes; the indurated interstitial structure 
which characterizes cirrhosis,* and granular degeneration of the 
liver and kidneys, and old cicatrices and consolidations very 
commonly met with in the lungs. The opaque, tough thickening 
of the valves of the heart, often attended with corrugation, con- 
traction, and rupture, and the similar change in the coats of arte- 
ries, appear to belong to the same class of deposits. 

554. The structure of these deposits deserves to be more fully 
investigated. They appear to possess some organization, being 
composed of irregular cells and fibres, with more or less granular 
or amorphous solid matter to complete their substance, (§ 424.) 
They, however, exhibit various degrees of organization, some 
being vascular, and some not; but they are all inferior to the 
structure with which they are connected, and to the euplastic 
deposits above described. Although rarely occurring in great 
abundance in an organ or structure, except from some hyper- 
semia of that part, yet, in a small extent, cacoplastic deposits are 
to be met with in most subjects at all advanced in life, and more 
particularly those who have long suffered from ill health. The 
opaque thickening of the membranes investing the liver, spleen, 
lungs, heart, and brain, often arborescent from its accompanying 
the course of the blood-vessels — the coarser and less regular 
granular appearance exhibited in parts of the liver and kidneys, 
especially at their most depending portions, the granules com- 
monly adhering to the capsule of the viscus when it is torn off — 

* The term cirrhosis (from an obsolete Greek word, xippo?, yellow) was first 
applied by Laennec to the granular degeneration of the liver; because the deposit 
is commonly yellow from being stained with bile. The term is obviously inap- 
plicable to contractile deposits in the lungs and other parts; to which, neverthe- 
less, the name has been applied. The epithets, granular or contractile deposit, 
are respectively more suitable to the forms in which this cacoplastic product 
manifests itself. 



DEPOSITS CACOPLASTIC GRAY TUBERCLE. 309 

the partial consolidations of the lungs, particularly near their 
apex — the opaque patches in the lining membrane of the heart 
and arteries, — are all specimens of the result of cacoplastic de- 
posits which age or disease has produced; and the more the 
nutrient function has been degraded in the individual, the more 
abundant will be the specimens of this cacoplastic deposit. But 
generally this deposit takes place more abundantly in one par- 
ticular organ, in consequence of disease predisposing it to suffer, 
(§ 31, 2.) Thus if a person, from habits of intemperance or 
other cause, has injured the function or structure of the liver or 
kidneys, in the lapse of time, as the nutritive function begins to 
fail from age or debility, the injured organ is the first to suffer, 
and becomes the subject of cirrhosis or granular degeneration; 
and this may destroy life by arresting excretion, &c. (§ 170, 311) 
before other organs are much affected. 

555. But there is another more general form of cacoplastic 
deposit, which takes place, when textural nutrition is degraded 
still further than in the preceding examples; this is in semi-trans- 
parent, miliary, gray, and tough yellow forms of tubercle. 
Instead of (with Laennec) classing tubercle under the vague term 
of " accidental productions," or (with Carswell) as a "secretion 
sui generis" I have for many years referred tubercle to a de- 
graded condition of the nutritive material from which old textures 
are renewed, and new ones formed; and have held, that it differs 
from fibrin or coagulable lymph, not in kind, but in degree, of 
vitality and capacity of organization.* These views have re- 
ceived almost demonstrative confirmation in the microscopic re- 
searches of Mr. Gulliver and others, which have detected in tu- 
bercle the materials of lymph, but in a degenerated and confused 
state, the cells being few, irregular, shrivelled, with imperfect 
nuclei, and incapable of further development; no fibres being 
perceptible, and the main substance being composed of granular 
or amorphous matter.! Every gradation may be found between 

* A somewhat similar opinion, but less definitely expressed, has been enter- 
terlained by Dr. Alison, and formerly by M. Andral; but these pathologists seem 
originally to have regarded tubercle chiefly as the product of a modified inflam- 
mation. 

f " Corpuscles more or less globular or oval are seen in tubercles; but the 
granular matter preponderates as the tubercular mass increases. Cells may be 
recognized in the miliary tubercles; bat as they increase in size, the well-marked 
omplete cells disappear. Tubercles appear to differ essentially from the 
plastic exudations, inasmuch as the cells of the latter not only grpw into a higher 
organization, but increase in number towards the centre; in other words, plastic 
matter bas an inherent power of multiplying and evolving organic germs. But 
tubercle bas ao such power; for it would appear that its primitive cells can only 
!■■ and degenerate." (Gulliver's Appendix to Gerbcr's General Anatomy, 
p. 87.) — "If a tubercle, or even the tissue of the lung mar it, be slightly com- 
pressed between two slips uf glass with a drop of water, it will crumble down 



310 STRUCTURAL DISEASES. 

euplastic and aplastic deposits; the cells and fibres which are the 
representatives of organization diminishing in number and com- 
pleteness, and the material becoming more granular or amorphous, 
in proportion as the deposit is degraded, until, in opaque, crude, 
or yellow tubercle, it is altogether aplastic, consisting of a mere 
aggregation of granules, with mere traces of the remains of cells. 

I consider that the more solid forms of tubercle are entitled to 
a place among cacoplastic deposits; because, although destitute 
of vascularity, they seem to possess a kind of structure, like that 
of the lower kinds of fibro-cartilage and granular deposit. Their 
affinity with granular degeneration is shown by their commonly 
occurring in the same subjects, and by their frequently exhibiting 
the same tendency to contraction. In a very large majority of 
cases of chronic granular degeneration of the kidneys or liver, 
there are found more or less traces of tubercle in the lung, its 
chief seat; and in very few instances of chronic phthisis have I 
failed to find some degree of granular disease in the liver or kid- 
neys. In acute phthisis and acute granular disease, local causes 
accelerate the degenerative change to a destructive extent in one 
organ, before there is time for others to become affected. 

556. Let us now trace the history of cacoplastic deposits in a 
few examples. The dense false membranes on the surface of 
serous membranes may be often seen surrounded by a radiated 
wrinkling or puckering of the adjoining parts, indicating that 

and break to pieces, the fluid being at the same time quite white or milky. This 
white appearance is attributable to a great number of minute objects, the assem- 
blage of which constitutes the substance of the tubercles. They consist for the 
most part of molecules, granules, and granulated corpuscles, of various sizes, of 
aggregated granules without any tunic, and of collapsed tunics without any 
granules. These objects are mingled with a great many shapeless flakes and 
filaments, which are no doubt fragments of the membrane of the air-cells, and of 
the minute blood-vessels, which, when involved in a tubercle, become so ex- 
tremely brittle, that they must necessarily form a considerable proportion of the 
objects occupying the field of the microscope. The granulated corpuscles of a 
tubercle are sometimes very large, (g fo or y^j of an inch; and the molecules 
and granules, which are very conspicuous, may frequently be seen on the point 
of escaping from them The semi-transparent forms of tubercle and tuber- 
cular infiltrations owe their peculiarity to a great relative amount of granulated 
vesicles, (cells, Gulliver,) whereas the opaque white forms of tubercle are attri- 
butable to great numbers of isolated granules." — Mr. Addison's "Experimental 
and Practical Researches, $c.,-" Trans. Provincial Med. and Surg. Association, 
1843, p. 287, 8. 

These quotations supply microscopic evidence in favour of views regarding 
the nature of tubercle, which I have long held and taught, and to which I was led 
by an attentive examination of the common characters and changes of lymph, 
pus, and tubercle. A brief notice of these views may be found in the four edi- 
tions of my little work on the " Pathology and Diagnosis of Diseases of the Chest;" 
in my " Lectures on Diseases of the Chest," published in the " Medical Gazette" 
of 1837, 8; and in the " Library of Practical Medicine," vol. iii. 1840. All these 
works were published long before any of the above microscopical examinations 
were made. 



DEPOSITS — CACOPLASTIC — GRANULAR TUBERCLE. 311 

the new depost has shrunk in size. A similar contraction is 
noticed in the deposits on and under the lining membrane of the 
heart and its valves, and causes a serious disturbance of their 
mechanism. The contraction of the chest in some cases of 
pleurisy is, in part, dependent on the same property of caco- 
plastic deposits. This general tendency of certain false mem- 
branes to contract was, I believe, first distinctly pointed out by 
Dr. Hodgkin; and the fact has been applied by Dr. Carswell to 
explain the contraction of the liver in cirrhosis, which he con- 
siders to depend on a deposit in the intravascular cellular texture 
prolonged from the capsule of Glisson. I do not consider that 
the contractile deposit in cirrhosis is exclusively confined to any 
texture. False membranes, which exhibit the same contractile 
property, are sometimes found on the free surface of serous mem- 
branes, and especially along the course of the vessels, (veins as 
well as arteries;) and on the liver and lung, depressions from 
atrophy of the substance of the organs are sometimes seen under 
these deposits. There can be little doubt that these deposits are 
merely exuded from the vessels in certain pathological states, 
(congestion, chronic inflammation, and malnutrition,) and form 
a dense structure of low vitality, which, by its subsequent con- 
traction, tends to constrict and compress the subjacent parts, and 
more or less to interfere with the passage of blood through them, 
and consequently with their secretion and nutrition. The same 
tendency is shown in the higher (less aplastic) forms of tuber- 
culous disease. Miliary or granular tubercles in the lungs, when 
in considerable numbers, and not soon softening, cause a con- 
traction of the lung, chiefly at the upper part, and a corresponding 
collapse in the upper part of the chest. I have met with many 
cases, in which a sinking in of the infraclavian region took place 
before any symptoms of softening or excavation had occurred; 
indeed, it is a very common sign of tubercles which long 
remain stationary. The still greater amoimt of collapse, in the 
advanced stages of tuberculous lesions, although partly dependent 
on other causes, is also in some degree connected with the con- 
traction of cacoplastic deposits in the lungs and pleura. In 
the peritoneum, agglutinated tubercles often cause considerable 
contraction; and I have seen the omentum thus puckered up into 
a knotty mass. 

It would be an interesting point to compare the microscopic 
structure of cacoplastic deposits before and after their contraction. 
1 1 is most probably that it is by the partial absorption of the 
granular or amorphous portion of the deposit, and by the closer 
approximation of the cells or more organized constituent, that the 
condensation takes place. Hence, it may be, that the structure 
so contracted is less liable to the further degeneration to which 



312 STRUCTURAL DISEASES. 

cacoplastic deposits commonly tend. Certain it is, that of different 
portions of cacoplastic deposit in the lungs and elsewhere, those 
that are contracted remain unchanged, whilst others pass into the 
aplastic state of opaque and softened tubercle. This contractile 
process seems, therefore, to raise the deposit to a higher standard, 
in which, although below them, it is tolerated by the adjoining 
textures. But this very change may seriously injure them, by 
contracting and compressing their vessels, and interfering with 
their nutrition and other functions. This is the chief mode in 
which the granular diseases of the liver and kidneys gradually 
infringe on the circulation and secretion of these organs, and thus 
may eventually prove fatal, (§ 249, 375.) The contraction which 
takes place near the summits and roots of the lungs, in the more 
limited and therefore chronic forms of pulmonary tuberculous 
disease, often lay the foundation of emphysema of the lungs and 
habitual asthma. I have notes of a large number of cases illus- 
trative of this fact; but such details belong to special pathology, 
and are reserved for another work. 

557. Having adverted to the less degraded or degenerating 
form of cacoplastic deposits, we have now to notice those of a 
lower character, which tend to become aplastic. These include 
the commoner forms of tubercle. In the granular, miliary, gray, 
or drab-coloured tubercles of serous membranes and parenchy- 
mata, we find a dense homogeneous solid, closely resembling some 
of the other cacoplastic deposits which have just been described. 
Their resemblance, and even identity, may often be well traced 
in chronic or subacute arachnitis, peritonitis, and pleuritis, in 
which portions of the affected membrane are covered with dif- 
fused patches of semi-opaque deposit, which no one would 
hesitate to call false membrane; whilst in other parts the same 
deposit, occurring in separate granules, exhibits all the characters 
of granular or miliary tubercle. But how comes it (may be 
asked) to assume the granular form? In answer to this question, 
I may refer to the observation made on the products of inflam- 
mation, (§ 449,) where it was pointed out, that the effusion of 
lymph on an inflamed membrane is at first granular, and would 
continue to be so, if it were not drawn or spread into threads or 
films by the friction or pressure of the surfaces where it is poured 
out; and several examples were cited, in which, from the ab- 
sence of such friction or pressure, the granular appearance is pre- 
served even in acute inflammation. In chronic inflammation, in 
which the matter effused is from the first less ductile and more 
consistent, the granular condition more generally remains; and 
it is generally admitted, that the product of chronic inflammation 
of the peritoneum and arachnoid is always more or less granular. 

But tubercles do not always result from inflammation. In 



DEPOSITS — CACOPLASTIC — TUBERCLE — CHANGES. 313 

many cases, they are found disseminated in so many textures, 
after few or no symptoms of inflammation, that it is impossible 
to regard them otherwise than as the result of modified textural 
nutrition. The cell-germs by which the material of textures is 
renewed, are imperfect at particular points; the granular or hya- 
line matter abounds and concretes without fibres or vessels being 
developed; at this point a hard granulation appears. Where a 
granule has once been formed, it becomes a nucleus for the con- 
cretion of more: a new habit or mode of nourishment is estab- 
lished at the spot; or, to speak less figuratively, cacoplastic 
matter (if present in the blood) concretes around it by a process 
similar to that by which fat attracts fat, or bone, osseous matter; 
perhaps the process is not wholly unlike that of crystallization. 
But however it happens, the result is, that the granular tubercle 
grows, and may attain the size of a millet-seed, hemp-seed, or 
even a small cherry-stone; or, being subjected to pressure, may 
somewhat spread or flatten into various shapes. 

558. But tubercles rarely grow much without exhibiting an- 
other change in their appearance. They lose their semi-trans- 
parency, and become of an opaque or dead, pale, yellow hue, like 
the colour of raw potato or parsnip. This is the transformation 
to crude yellow tubercle first described by Laennec. This change 
is the result of a further degradation of the deposit. The few 
cells which are to be detected in gray tubercle become indistinct, 
and the mass is merely granular, and therefore quite aplastic. 
Generally the change begins in the centre of the mass, apparently 
because, being devoid of vessels, the centre is further removed 
from the vivifying influence of the blood. Yet congestion or in- 
flammation in the neighbourhood seems to accelerate this change 
just as they hasten the conversion of lymph into pus, the plastic 
into the aplastic, by the increased warmth and afflux of fluids pro- 
moting the degenerative change — the loss of vitality — to which 
tuberculous deposits tend. 

559. But tubercle is frequently deposited at first in this yellow, 
opaque state, this circumstance being a mark of the still more 
degraded condition of the nutritive function; and the more exten- 
sive forms of tuberculous disease commonly abound in this aplas- 
tic matter. Thus in rapid phthisis, whether resulting from acute 
inflammation or from the prevalence of scrofulous (cacoplastic) 
diathesis, yellow tubercle commonly forms a large portion of the 
deposit; and it is in these cases that its resemblance to, and con- 
nection with, coagulable lymph may be best seen.* Yellow 

• The affinity between lymph and tubercle was recognized by older writers; 
but after it had been kept out of view by the too exclusive opinions of Bayle and 
Laennec, it was again fully pointed out by Dr. Alison. (Trans, of Medico- 
Chirurg. Soc. of Edin., vols. i. and ni.) 
21 



314 STRUCTURAL DISEASES. 

tubercle is rarely so hard or so tough as the gray or semi-trans- 
parent kind; and in the cases of rapid deposit just mentioned, it 
is often much softer and more friable. Now, this is the com- 
mencement of a change to which the lowest forms of tubercle 
tend — that of maturation and softening into a cheesy substance. 
The conversion of the gray into opaque tubercle, and the further 
softening of this, seem to be the converse of the contractile pro- 
cess to which the higher class of cacoplastic deposits tend: in that, 
(the contractile process,) the deposit becomes more dense and 
organized: in this, (opaque change and softening,) the deposit 
becomes less dense, and loses the little trace of structure which 
it had: it degenerates into an amorphous, granular mass; and 
being lifeless, it is no longer nourished; but its granules lose their 
cohesion, and become disintegrated by the chemical action of the 
adjoining fluids.* Mr. Gulliver has also observed an appearance 
of fat globules into softened tubercle. The formation of these in 
old pus, (§ 460,) in atheroma of arteries, and in gangrene of the 
lungs, seems to show that fat is sometimes a debris of animal 
matter, as in the conversion of flesh into adipocire, (§ 543.) The 
lenticular corpuscles concentrically striated, supposed by Gruby 
to be characteristic of softened tubercle, Mr. Gulliver has found, 
in various textures, unconnected with tubercle or any other dis- 
ease. The detection, by Dr. Davy, of oleine and margarine in 
opaque exudation corpuscles, (§ 543,) shows a tendency to the 
production of fat in all degenerated plasma. 

560. But in these different changes in tuberculous matter, as 
well as in the original deposition of this matter, the adjacent 
living parts have a considerable share. A miliary tubercle from 
its first formation may become a cause of irritation and obstruc- 
tion to the contiguous textures. The amount of this irritation 
and obstruction will depend on the natural or present vascularity 
and excitability of the part, its function, and the situation and size 
of the tuberculous deposit. Thus, in vascular textures, especially 
parenchymata, there is more tendency to mischief and change 
than in serous membranes. Where the irritation is very slight, 
it may merely cause so much determination of blood as to promote 
the growth of the gray tubercle. Where it is more, it may cause 
the conversion of gray into yellow tubercle, its further increase in 

* Dr. Elliotsori,I think, first suggested that the softening of tubercles is due to 
a spontaneous chemical change. I also consider .ne change to be chemical; but 
to arise from the action of fluids from adjoining parts. So long as tubercles are 
kept free from superfluous moisture, they manifest little disposition to change; 
but an afflux of fluids around them hastens their maturation and softening. This 
effect may be rudely illustrated by the action of water or serum on coagulated 
albumen. When nearly dry, it is tough and semi-transparent; but when well 
moistened, it becomes opaque, soft, and friable. The softening of clots of fibrin 
by warmth and moisture gives another illustration of the same change. 



DEPOSITS AFLASTIC TUBERCLE AND ITS CHANGES. 315 

this form, and its softening. If the irritation be still greater, in- 
flammation is excited around the tubercle; and the products of 
this inflammation (pus, lymph, mucus, serum, &c.) may also 
hasten the softening of the tubercle, their mixture together, and 
their evacuation by ulceration into adjoining open surfaces. Or, 
the product of inflammation being more solid and plastic, consoli- 
dations, or false membranes, are formed around the tubercle, and 
its irritating influence may be thus reduced. And although we 
have just mentioned that the opacity, maturation, and softening 
of tubercle, depend essentially on a further degeneration and loss 
of structure, yet these changes are much promoted by the afflux 
of blood to the neighbouring parts. 

561. In the absence of any of the circumstances just mentioned, 
which tend to promote the increase or further change of tubercle, 
we find that it may remain harmless for months, and even for 
years; but then it often exhibits the transformations which may 
be considered spontaneous. The change of the less cacoplastic 
deposits by contraction has been already noticed, (§ 556.) In the 
lungs, the consolidations may remain long without any contrac- 
tion, but they become deeply blackened by an accumulation of 
the peculiar black matter of the lung. Yellow and softened 
tubercle, if not evacuated in time, become replaced by a plastery, 
or putty-like matter, composed chiefly of phosphate of lime, and 
often containing solid concretions, consisting entirely of that earthy 
matter. This petrifactivc change reminds us of what takes place 
in the cacoplastic deposits in the coats of arteries and on serous 
membranes, (§ 544, 553,) constituting what is erroneously called 
ossification. The calcareous conversion of tubercle can be ex- 
plained only on the supposition that the animal matter is absorbed, 
and the earthy matter is deposited in its place. This is exactly 
like what takes place in true petrifaction of organized bodies, the 
silica or calcareous substance being substituted molecule for 
molecule: so that, when all is converted into stone, the shape of 
the organized body is retained. But we further learn from this 
that the animal matter of tubercle may be absorbed. This occa- 
sional absorption of tuberculous matter is further proved by its 
accumulation in the bronchial and mesenteric glands, which 
sometimes contain it when the lungs and the intestines contain 
little more than traces of it, such as cicatrices, with some creta- 
ceous mattei in them. In the bronchial glands, too, the lubeivle 
very commonly exhibits the petriiaotive change, and the concrer 
tii »ns so commonly found in these glands may generally be ascribed 
to this cause. 

5G2. The circumstances which degrade the material of nutri- 
tion, and lead to the deposition of cacoplastic and aplastic matter, 
may be either local or general. Of the local causes, congestion 



316 STRUCTURAL DISEASES. 

and the lowest and more chronic forms of inflammation have been 
mentioned as capable of determining cacoplastic deposits; but 
even in these cases it is probable that the general cause also more 
or less operates — that is, a degraded state of the plasma of the 
blood. Congestions and chronic inflammations certainly cause 
cacoplastic effusions; but then, such congestions and chronic in- 
flammations do not easily occur in healthy subjects; and the want 
of health may imply that the plasma of the blood is bad in addi- 
tion to the local cause. But practically, it is of great importance 
to keep in view the local as well as the general cause, for the 
former is often more tractable than the other, and it is by guarding 
against it that slighter degrees of the general cause (diseased 
plasma) may be prevented from doing mischief. But the gene- 
ral cause, when present in great degree, leads to cacoplastic and 
aplastic deposits, as modifications of ordinary textural nutrition, 
independently of inflammation or even congestion. This general 
cause thus prevailing constitutes the chief element of the scrofu- 
lous diathesis or tuberculous cachexia, and we have before 
mentioned that a defect of the red particles and an excess of fibrin 
in the blood constitute its most remarkable feature, (§ 1S5, 211.) 
In this condition of the blood there is an increased disposition to 
deposit, and often an abundance of the fibrinous or nutritive 
material, but an imperfect vitality or organizability of this mate- 
rial, so that when deposited, instead of being assimilated to the 
textures, it forms the degenerated structures or mere granular or 
amorphous deposits, which we have been describing. But with 
this condition of the blood, these deposits must be greatly pro- 
moted by all varities of hyperemia, and prevail most in organs 
which receive the largest amount of blood. Hence, the peculiarly 
pernicious effect of inflammation of internal organs, especially the 
lungs, in scrofulous subjects. Even acute inflammation may be 
unequal to raise the nutritive material to a plastic standard at 
which it may be organized or absorbed, or to mature it to the 
process of complete suppuration by which it may be speedily 
excreted; but the matter thrown out is cacoplastic, or curdy 
lymph, or a caseous kind of pus, inorganizable, inert, irremovable 
by absorption, and permanently obstructing or compressing the 
structures in which it accumulates, until it gradually excites an 
irregular destructive suppuration or ulceration, forming vomica3,or 
imperfect abscesses pervading the structures, and without walls 
capable of healing, whilst the body wastes with hectic fever, 
night-sweats, and colliquative diarrhoea. So likewise fevers, by 
causing congestions in organs, lead to the production of a crop of 
these deposits, from which tuberculous disease takes its origin. 

563. The lungs and bronchial glands are by far the most com- 
mon seat of tubercles; when found elsewhere, tubercles commonly 



DEPOSITS CACOPLASTIC AND APLASTIC TUBERCLE. 317 

abound more, and are more advanced in these parts. The situa- 
tion of the prevalence of tuberculous disease varies also with the 
age of the subject. Thus, M. Papavoine found yellow tubercle 
in children to occur especially in the cervical and mesenteric 
glands; next, in the spleen, pleura, liver, and small intestines; less 
frequently, in the large intestines and peritoneum; and more 
rarely in other parts. In 350 consumptive cases examined by 
M. Louis, tubercles were found in the small intestines in one- 
third of the whole; in the mesenteric glands, in one-fourth; in 
the large intestines, hi a ninth; in the cervical glands, in a tenth; 
in the lumbar glands, in a twelfth; in the spleen, in a fourteenth 
of all the cases; and in other parts, in smaller proportions. 

The greater liability of the lungs to tuberculous deposits, has 
been lately ascribed by Dr. Campbell and others to the finer size 
of their capillary vessels, which causes them to act as filters to 
the blood, arresting the tuberculous matter which is supposed to 
become solid in the blood itself. But this view is untenable for 
several reasons. 1. If the fine size of capillaries were the chief 
cause of the deposit, it should take place abundantly in muscle, 
the capillaries of which are even finer than those of the lungs. 
2. If the cause of the first deposit were a solid matter obstructing a 
vessel, the appearance of vascular distension and obstruction 
would be obvious in the earliest formation of tubercles, and the 
deposit would exhibit somewhat of a capilliform shape, which is 
not the case. 3. The deposit has been distinctly traced by Messrs. 
Gulliver and Addison to be extra-vascular, sometimes on the sur- 
face of the air-cells, and sometimes in or under the membrane 
composing them. I think it highly probable that tuberculous 
matter may form within the blood-vessels themselves; and I have 
repeatedly found something presenting all the external characters 
of yellow tubercle in the blood-vessels of tuberculous lungs. In 
fact, wherever fibrin may coagulate, there its degraded form, 
tubercle, may occur; and I cannot but refer to the case of opaque 
softening of clots of fibrin in coagula in the heart and great blood- 
vessels as bearing on this point. Formerly, this softened fibrin 
was mistaken for pus; Mr. Gulliver pointed out this error by 
showing that it had no pus globules. But its aspect and micro- 
scopic composition differ in no essential particular from those of 
soft tubercle, and the views which I have given would identify 
them m nature. This leads me to infer that the fibrin of blood 
Stagnant within vessels, or extravasated from them, in tubercu- 
lous Bubjeets, may sometimes change into aplastic tubercle. But 
the reasons before stated make it obvious that the early forms of 
tubercle are extravaseuiar deposits, resulting from modifications 
of the ordinary nutritive secretion. 

1 believe that several circumstances contribute to render the 
27* 



31 S STRUCTURAL DISEASES. 

lungs especially liable to tuberculous deposit. 1. Their great 
vascularity and the large quantity of blood that passes through 
them. 2. Their being a chief seat of the formation of fibrin, 
that principle being more abundant in arterial than in venous 
blood, (§ 194.) 3. The softness and yielding nature of their 
texture, which permits effusion to take place more readily than 
denser textures do. 4. Their exposure to external causes of dis- 
ease, whether by cold and irritations directly entering by the 
air-tubes, or by circumstances operating through the medium of 
the circulation. In hot climates, cacoplastic diseases affect the 
liver and other abdominal viscera more than the lungs; the same 
persons there suffering from liver disease and dysentery, who, in 
a cold climate, would fall victims to phthisis. 

564. As we have found (§ 562) that the cacoplastic condition 
of the blood of tuberculous or scrofulous subjects comprises a 
diminution of the red particles and a preponderance of fibrin, so 
we can state that the causes which develop this condition, and 
therefore induce tuberculous disease, are such as intelligibly in- 
duce one or both of these changes. Insufficient food, want of 
pure dry air, of warmth, and of light, long-continued mental 
depression, aggravated and prolonged disease of the digestive 
organs, insufficient excretion, (§ 249,) and the injurious influence 
of fevers and other serious diseases, are acknowledged causes of 
tuberculous disease, and may be considered to operate in both 
ways. Excessive evacuations of blood, or of the more annualized 
secretions, and severe courses of mercury, also predispose to phthi- 
sis, and may perhaps act chiefly by reducing the red particles of 
the blood. The cessation of growth, the termination of preg- 
nancy, the stoppage of habitual discharges, especially purulent, 
and the ampul ation of a limb, all of which circumstances are 
known to favour the development of tubercle, may be supposed 
to operate chiefly by increasing the proportion of fibrin in the 
blood, when there is not a sufficiency of red particles, and of vital 
power, which is represented by them, (§ 183,) to give to this fibrin 
a due amount of vitality. 

565. The treatment of cacoplastic and aplastic deposits, and 
of the conditions which lead to them, involves a vast number of 
details, according to their kind, situation, extent, and other cir- 
cumstances in which they occur. It is not consistent with the 
limits of this work to enter into these details; but it is hoped that 
a rational view of the principles on which these deposits are to 
be prevented and treated may be deduced from the foregoing 
account. This view will comprehend those measures which have 
the best sanction of experience. 

The elements of disease chiefly to be kept in view in the 



DEPOSITS — CACOPLASTIC AND APLASTIC — TREATMENT. 319 

treatment are: — 1. the disordered condition of the blood, and 
its causes; 2. the disordered distribution of the blood, and its 
causes; and 3. the presence of the deposit, and its effects and 
changes. The second element comprehends the varieties of local 
hyperemia, which we have found to be so much concerned in 
producing the higher kinds of cacoplastic deposit, (§ 553,) and 
in promoting the formation and changes of those of a lower 
character, (§ 560.) Hence, the remedies against inflammation, 
determination of blood, and congestion, are frequently more or 
less needed in the prevention and treatment of cacoplastic and 
aplastic deposits. But, except as preventives, the utility of this 
class of remedies is generally limited to those of a topical kind, 
such as local blood-letting, counter-irritants, revulsives, derivants, 
and alteratives, (§ 174.) 

566. The more constant and important element to be con- 
sidered, in the treatment of cacoplastic and aplastic diseases, is 
the first named — the diseased condition of the blood; and this 
more demands attention, the more general and the more degraded 
are the deposits. The first point to be attempted is the removal 
or counteraction of the several causes before enumerated, (§ 564,) 
as contributing to induce the diseased condition of the blood. 
Thus a sufficient supply of food of a nutritive quality — free ac- 
cess of pure dry air and light, while the warmth of the body, 
particularly of the surface and extremities, is carefully secured — 
the removal or counteraction (so far as is possible) of diseases 
impairing digestion and excretion, and of depressing mental or 
bodily influences, — are among the first objects to be aimed at in 
treating cacoplastic diseases. Where excessive losses of blood 
or other evacuations have contributed to lower the plastic process 
of nutrition, a generous animal diet, and tonics, especially those 
containing iron, are especially indicated. Where the altered con- 
dition of the blood can be traced to an excess of ill-developed 
fibrin accumulating after the cessation of growth, the termina- 
tion of pregnancy, the amputation of a limb, or the sudden 
stoppage of an habitual purulent or other discharge — means to 
eliminate the superfluous matter from the blood, either by in- 
creasing the natural secretions, or by establishing an artificial 
drain by blisters, sctons, issues, suppurating counter-irritants, &c., 
arc distinctly indicated; whilst tonic and invigorating measures 
may be also useful to raise the plasticity of the blood to a higher 
standard. 

The foregoing measures may be considered rather as preventive 
than curative; bul in so far as they may succeed in arresting the 
growth <>f deposits already formed, and in improving the nutritive 
function in general, they will favour the limitation of the deposits, 
and their gradual absorption or quiescence in contraction (§ 556) 
or calcareous transformation, (§ 561.) 



320 STRUCTURAL DISEASES. 

567. The third object to be regarded in the treatment is the 
deposit that is already formed. In this case, as in most others of 
diseased structure, medicine can do but little. Unlike the euplastic 
products of inflammation, and, in some instances, unlike a simply 
overgrown texture or organ, the changes of absorption scarcely 
reach unorganized matter; and it is doubtful whether any remedy 
that we can use will materially promote its removal, unless, per- 
haps, by the simultaneous destruction of the texture which con- 
tains the deposit. Mercury has seemed to me to hasten the 
softening and evacuation of pulmonary tubercles; but this is by a 
work of destruction, and its influence on the blood has been 
already mentioned to be injurious. Drs. Graves, Stokes, and 
others, have, however, recommended mercury in the earliest stage 
of tuberculous disease. My own experience would lead me to 
avoid the specific influence of mercury hi all cases of mere tuber- 
cle; but I have given it with advantage in cases of subacute and 
chronic inflammation simulating tuberculous disease, and even 
where tubercle probably existed in a limited extent. Whether 
mercury is of any use in granular disease of the liver and kidney, 
is also a subject of doubt. Alkalies and their carbonates, and 
iodide of potassium, have better claims to notice, although their 
power to dissolve cacoplastic and aplastic deposits is very uncer- 
tain.* The occasional subsidence of external scrofulous tumours 
under their use is the best argument in their favour; and they 
have this advantage, that when judiciously administered, they do 
not injure the blood or the constitution. They act best, and are 
longer borne, when combined with fluid extract of sarsaparilla 
and tincture of hop, or some other narcotic; and I have found 
this combination more useful than any other in the early stages 
of tuberculous disease, where there is no fever, active inflamma- 
tion, or tendency to haemorrhage. Whether the iodine and alkali 
ever directly promote the solution or absorption of tuberculous 
matter, I am still in doubt; but the signs of the presence of limited 
tubercles have, in many instances, diminished during their use, 
and the patients have regained colour, flesh, and strength. Other 
combinations of iodine, particularly with iron, have been recom- 
mended in scrofulous disease. The iodide of iron, and other pre- 
parations of this metal, I have found very beneficial in cases of 
anaemia or general weakness without much fever or local inflam- 
mation; but I have seen no reason to suppose that they promote 

* The discovery of a considerable amount of a fatty constituent in cacoplastic 
and aplastic deposits (§ 559, 479) again suggests the idea that alkalies may act 
chemically by saponifying and dissolving this fat. A similar notion seems to 
have led Dr. Hastings to use naphtha in the early stage of tuberculous consump- 
tion; and he gives a glowing report of its efficacy. I have not given this medi- 
cine a trial sufficient to enable me to judge of its utility. 



PERVERTED NUTRITION MORBID GROWTHS. 321 

the removal of tubercles already formed. The same may be 
said of bark and quinine, which are, however, sometimes very 
useful in reducing hectic fever, when it assumes an intermittent 
form. 

568. During the ulterior degeneration of cacoplastic deposits 
into yellow and caseous tubercle, there are generally symptoms 
of increased weakness and deterioration of the blood, with more 
rapid emaciation, profuse night sweats, &c. At this period, 
mineral acids are sometimes useful, particularly the nitric and 
nitromuriatic, which may be given with sarsaparilla or stronger 
tonics, if they are borne; and a more supporting diet, if the appe- 
tite and digestive powers will admit of it. 

We know nothing of means to directly favour the quiescence 
of cacoplastic deposits by contraction, and of aplastic matter by 
petrifaction. Can the chloride of calcium, which was formerly 
an esteemed remedy in scrofula, in any way contribute to the 
latter change? 

Although I have dwelt somewhat longer on the measures con- 
nected with the third indication, (to remove or influence deposits 
already formed,) because they are more peculiar, I again repeat, 
that these are less efficacious, and more doubtful in their opera- 
tion, than those adverted to — but not detailed — to fulfil the first 
two indications, (to improve the condition of the blood, and to 
equalize its distribution;) the judicious application of these consti- 
tute the most important points in the prevention and treatment of 
cacoplastic and aplastic deposits. 

MORBID GROWTHS. 

569. Under the term morbid growths, may be arranged certain 
structures developed in the animal body in addition to the natu- 
ral textures. They differ from hypertrophy and euplastic depo- 
sits in the peculiarity of their structure; and from cacoplastic and 
aplastic deposits, in their possessing a higher degree of organiza- 
tion. In other words, they differ from hypertrophy and euplastic 
formations in their kind of vitality; and from degenerations and 
cacoplastic deposits, in their degree of vitality. They arc, in fact, 
new structures; and although some of them in general characters, 
and most of them in elementary composition, resemble some of 
the natural textures of the body; and although all derive their 
nourishment from the blood; yet, in their origin and growth, they 
;uv more essentially distinct from the natural structures than are 
any of the results of diseased nutrition hitherto considered. For 
these reasons, they I iave been called new and parasitical growths; 
and the term parasitical is the more applicable t<> them, because 
their existence and moth; of growth cannol generally he traced to 



322 STRUCTURAL DISEASES. 

variations in the local circulation, which we have found to be 
chiefly concerned in producing and influencing the modifications 
of nutrition hitherto noticed. 

Morbid growths have been divided into analogous, those 
whose structure resembles some natural texture, (including false 
membranes, &c;) and non-analogous, or heterologous, those 
which have no parallel in the healthy state of the animal eco- 
nomy. But this division is inconvenient, because it is applied to 
the other products of diseased nutrition previously arranged under 
another division; and it is often inapplicable, inasmuch as many 
morbid growths are essentially compound, comprising some forms 
that resemble natural textures, others that do not; yet all these 
are constituted of similar elementary molecules: this remark espe- 
cially applies to carcinoma. 

The division which I have adopted into non-malignant and 
malignant is more useful in a practical point of view, although it 
may not be easy to make it precisely applicable to all cases. 



SECTION VII. 

NON-MALIGNANT GROWTHS. 

570. I would apply the term non-malignant to those growths 
which occur in a part of the body, without tending to infect other 
parts; and which arise among, but do not invade, the natural 
structures; and if they prove injurious, it is by their bulk or posi- 
tion, or by the extent to which they abstract the nourishment of 
the body. 

571. The most simple form of new growth is the serous cyst, 
which is a shut sac, "containing serum, and formed of condensed 
cellular substance resembling serous membranes, which are 
formed gradually around a clot of blood, or any foreign substance 
in the system; and are frequently developed spontaneously in va- 
rious parts of the body. They are frequently attached to the 
natural serous membranes, but sometimes quite separate from 
these; sometimes solitary; sometimes set together in clusters; and 
their size and shape are very various. They must be distin- 
guished from enlargements of natural cavities, such as the calices 
of the kidneys, or Graafian vesicles in the ovaries. They are 
often unconnected with disease of the adjacent textures; but in 
some cases, these textures are found either wasted by absorption, 
(atrophy from pressure, § 532,) or disorganized by inflammation 
around them. There is no evidence of their being generally con- 
nected, in then commencement, with inflammatory action; and 



MORBID GROWTHS — NON-MALIGNANT — CYSTS, ETC. 323 

when they are small, their existence is often not denoted by any 
symptoms whatever."* 

Besides the instances above excepted from this class of new 
growths may be mentioned several others, which are rather in- 
stances of hypertrophy, dilatation, or unusual development of a 
natural structure, and therefore belong to a former division, 
(§ 528.) The enlarged bursas, in parts subjected to pressure; 
the dilated mucous follicles, in the cervix uteri; the cutaneous 
follicles distended with fatty or other matter, (epidermis scales,) 
constituting the subcutaneous adipoma and melliceris; the sali- 
vary ducts obstructed and filled with concretion, in the tumour 
called ranula; are of this kind, and do not belong to the pre- 
sent division. I would, with Dr. Hodgkin, extend the same re- 
mark to the small serous cysts frequently found in the kidneys 
and liver, which I have before described as portions of secretory 
ducts obstructed and distended with serum, (p. 161, note.) It 
may be fairly questioned whether other serous cysts are not also 
due to enormous enlargement of the primitive or compound cells 
of which textures are partly composed. My friend, Dr. Hodgkin, 
has most plausibly advocated an opinion of this kind, and has 
applied it also to explain the production of more solid and com- 
plex growths, by the formation, multiplication, and compression 
of a series of cells.t 

572. Cysts, like the serous cysts above described, are sometimes 
found filled with different contents, and then constitute the sim- 
plest kind of encysted tumours, which may form probably in any 
part of the body that has the cellular structure, and have received 
names descriptive of their contents: — " hygroma, when they con- 
tain a nearly serous or sero-purulentj (?) fluid, and form encysted 
dropsy if they be of very large size; hsematoma , when their con- 
tents are bloody; steatoma, when they approach more nearly to 
the appearance and consistence of fat; and atheroma, or cold or 
chronic abscess, when they contain purulent (?) matter of more 
or less consistence, without having been preceded by distinct 
marks of inflammation. Sometimes substances distinct from any 
found in the healthy body, or substances which in the natural 
state exist only in individual parts of the system, (e. g.,cholesterin,) 
are found in the interior of these encysted tumours. Those tu- 
mours of this kind which are of considerable size are often 
formed of a congeries of such cysts, and their contents in the 
Bame tumour are often very various, as is seen remarkably in the 
most common case of enlargement of the ovary, which appears 

• Alison's " Outlinrs of Pathology," p. 231. 
•f- Med. Chir. Trans., vol. xv., part 2. 

4 More probably, the fluid is turbid, from epithelium scales or degenerated 
exudation corpuscles. 



324 STRUCTURAL DISEASES. 

to consist in gradual distension and alteration of the fluid contents 
of the Graafian vesicles. Further, not only the contents, but the 
coats or envelopes of these cysts, are subject to a great variety 
of changes, becoming in some cases fibrous or cartilaginous, or 
having bony" (calcareous) " matter deposited irregularly through 
them."* 

573. Dr. Hodgkin considers that the complex cystiform tumour, 
as it occurs in the ovary, exhibits a type of the origin of morbid 
growths in general, not excepting those of a malignant kind. 
From the internal walls of one original or parent cyst, there 
spring a number of other cysts, varying in their contents, and as 
they grow, they fill the original cyst, and project beyond it, other 
cysts being produced within them; and thus a growth takes 
place, subject to modifications from the nature of the texture 
which is its seat, as well as from the contents of the cysts. In 
solid structures, as dense cellular membrane, the cysts are so 
compressed as to present the appearance of fibres radiating from 
a centre, and they lose all their liquid contents. The adjoining 
textures, as well as the walls of the cells, may also inflame and 
cohere, so as to obliterate the cystiform structure of the tumour. 
Professor Alison adverts to the connection between encysted and 
solid, or sarcomatous tumour in the commencement of the fol- 
lowing passage: — 

" In many cases, though not in all, we can clearly distinguish 
from these encysted tumours, (where the organized secreting sub- 
stance is external to the chief bulk of the morbid growth,) tu- 
mours, the organization of which is so far different, that their 
substance is penetrated throughout by a vascular cellular or 
fibrous structure, in which they are nourished, and by which 
they are often divided into lobules. These are generally called 
sarcomatous tumours; and the simplest example is the common 
vascular sarcoma, which consists merely of condensed cellular 
substance," (well supplied with blood-vessels,) "and may be 
found in any cellular texture, but is often seen in the mammse 
and testes. But, according to the different situations they may 
occupy, and the different textures of which they may consist, 
(sometimes, probably, from their original formation, and some- 
times in consequence of their gradual transformation,) tumours of 
the same general structure have received different names, adi- 
pose sarcoma, or ceroma, when of fatty or waxy consistence; 
poli/pus, when projecting from, and often closely resembling the 
structure of, mucous membrane; neuroma, when seated on a 
nerve, or when growing on its sheath, and splitting up and sepa- 
rating its fibrils; chondroma or fibrocartilaginous tumour, when 

* Alisons's " Outlines of Pathology," p. 233. 



MORBID GROWTHS NON-MALIGNANT SARCOMA, ETC. 325 

traversed by numerous bands or striae of the consistence of carti- 
lage; and osteosarcoma, when containing much bony deposition. 
In many instances, the difference in these morbid textures may 
be ascribed to their partaking more or less of the nature of the 
sound texture in which they are developed; but hi some, no simi- 
larity of the diseased structure to the surrounding healthy parts 
can be observed. In some cases,, as, e. g., in the coats of the sto- 
mach and intestines, it may be observed that the formation of such 
morbid growths is preceded by simple thickening and hardening 
of the sound cellular texture, a part of which only afterwards 
assumes the strictly morbid appearance."* 

574. The pathological cause of morbid growths is involved in 
much obscurity. We cannot at present go beyond the supposi- 
tion that they arise from altered vital properties in some of the 
molecules of the textures in which they are developed; so that, 
instead of being assimilated to these textures, and conforming to 
the laws of their growth and decay, these molecules grow of 
themselves in modes more or less peculiar, and more or less in- 
dependently of the influences of the adjoining living parts. 
Where these modes are less peculiar and more dependent on the 
nutrition of the adjacent structures, the growths are less abnor- 
mal, vary less from these structures, and more resemble either 
hypertrophy (§ 525) or euplastic deposits, (§ 547,) and they do 
mischief rather by their size or situation than from their intrinsic 
nature. Where the mode of growth is more peculiar and more 
independent of that of the textures in which they arise, the re- 
sulting tumours are more abnormal in their nature and mode of 
development; they approach in character to malignant disease, 
acting injuriously, not only by their bulk and position, but also by 
abstracting the nourishment of the body, and by tending to super- 
sede the. natural structures. 

575. At the outer limits of the non-malignant growths may be 
classed those peculiar bodies, called hydatids or acephalocysts. 
These are more peculiar in structure and contents than any other 
morbid growth, and they are quite detached from the structures 
in which they occur. They may therefore be inferred to possess 
a vitality quite independent of that of these structures. Their 
vitality is low, but indisputable, and is exhibited (1) in their 
power of self-nutrition, as manifest in the growth and the pecu- 
liar structure of their walls, which are much more clastic than 
any normal animal texture; (2) in their power of secretion, shown 
by the peculiarity of their contents, which are limpid and colour- 
less, whatever be the nature of the matter in the serous cyst 

• Alison, loc. cit. 
28 



326 STRUCTURAL DISEASES. 

which separates them from the living textures; (3) in their power 
of reproduction by gemmation, the young being developed be- 
tween the layers of the parent cyst, and thrown off either inter- 
nally or externally according to the species. Professor Owen* 
describes the hydatid to be " an organized being, consisting of a 
globular bag, which is composed of condensed albuminous mat- 
ter, of a laminated texture, and containing a limpid colourless 
fluid, with a little albuminous, and a greater proportion of gela- 
tinous substance." He adds, "As the best observers agree in 
stating that the acephalocyst is impassive under the applica- 
tion of stimuli of any kind, and manifests no contractile power, 
either partial or general, save such as evidently results from elas- 
ticity — in short neither feels nor moves — it cannot, as the animal 
kingdom is at present characterized, be referred to that division of 
organic nature. It would then be a question, how far its chemical 
composition forbids us to rank the acephalocyst among vegetables. 
In this kingdom, it would obviously take place next those simple 
and minute vesicles which in the aggregate constitute the green 
matter of Priestley, (Protococcus viridis, jlgardh ;) or those 
equally simple but different coloured psychodiariie, which give 
rise to the red snow of the arctic regions, [protococcus kerme- 
sianits.) These 'first-born of Flora' consist, in fact, of a simple 
transparent cyst, and propagate their kind by gemmules developed 
from the external surface of their parent." 

The researches of Schleiden, Schwann, and their followers, have 
thrown some light on the possible origin of hydatids, by showing 
that the primitive cells of animal, as well as of vegetable, struc- 
ture, are often not unlike hydatids in their anatomical compo- 
sition, growth, and mode of reproduction; for the hydatid appears 
to be a nucleated cell, from the interior of which are developed 
nuclei and nucleoli, the germs of young cells. But if it be pre- 
sumed, in accordance with this fact, that hydatids are really 
offsets of living structure, capable of living detached from the 
solids of the body, it still remains a mysteiy how this divided or 
detached life is acquired by certain molecules on rare occasions, 
and contrary to the usual law. We might perhaps imagine some 
analogy between hydatids and the polype tribe of animals, which 
may be indefinitely propagated by division; and it might be con- 
jectured that the conditions of the body in which hydatids are 
most commonly found, might reduce the plasma of certain parts 
to the standard of this mode of life; but these subjects are too 
speculative to be dwelt on here. 

576. The situations in which hydatids have been most com- 
monly found, are the liver, the lungs, the spleen, the kidneys, 

* " Cyclopaedia of Anatomy," &c, article Entozoa. 



MORBID GROWTHS NON-MALIGNANT TREATMENT. 327 

and the ovaries. M. Andral records an instance in which he 
found hydatids in the blood within the pulmonary veins; there 
was also a large cyst full of hydatids in the liver. The condition 
of the system in which they have been most frequently found to 
occur, is one of cachexia and mal-nutrition. They are usually 
contained in a serous or protective cyst (§ 571) formed by the 
texture around them; and the sjrmptoms which they occasion 
are merely those caused by their bulk and position, compressing, 
displacing, and irritating organs, and causing atrophy and in- 
flammation of their textures. In the cyst which contains them, 
there is commonly found more or less opaque laminated matter, 
which appears to be the debris of collapsed hydatids; indeed, 
some of those retaining the globular form often exhibit the com- 
mencement of this decay, in an opacity and wrinkling of their 
walls, and a changed colour of their contents. 

577. The echinococcus is a variety of hydatid, differing from 
the preceding chiefly in its having a yellowish and tougher outer 
tunic, and in its containing distinct animalcules within it, (yermi- 
culus echinococci.) It has been found in the liver, spleen, and 
mesentery, and rarely in the urine. The cysticercus is found in 
muscular structure, and in one instance was seen in the aqueous 
humour of the eye. It has a distinct structure, consisting of a 
cystiform body, and a head provided with suckers and hooklike 
processes for attachment. The distoma hepaticwn, or liver- 
fluke, is rarely found in the human subject. It is the supposed 
cause of the rot in sheep, and was found by Andral and Delafond 
in those animals in which dropsy was present, and there was a 
defect of albumen in the blood, (§ 222.) The rot is a disease 
which chiefly attacks sheep fed in wet clayey pastures. 

The subject of intestinal worms belongs properly to special 
pathology. 

578. Little can be said on the medical treatment of morbid 
growths. To those of the kinds most approaching to the natural 
textures may be extended the observations applied to hyper- 
trophy (§ 529) and euplastic deposits, (§ 552.) So far as they 
originate from, or are augmented by, local determination of 
blood, or any other kind of hypersemia, the remedies for these 
morbid elements may retard the increase of the growths. But 
as we have found that the chief peculiarity and cause of these 
growths is an alteration of the vital properties of the primitive 
molecules of textures, little is to be expected from measures 
which acl only on the quantity of the autritive material. In 
fact, we have seen that, in many instances, morbid growths seem 
to originate in connection with a depressed rather than with an 
exalted condition of the vascular functions; and in those last 



328 STRUCTURAL DISEASES. 

noticed, which bear more distinctly the character of parasites, 
the general or constitutional powers are weakened in proportion 
as these are developed. Hence, the general treatment indicated 
in such cases is of the supporting and tonic kind, with due at- 
tention to the regulation of the digestion and of the secretions. 
But this treatment will require modification when the morbid 
growths, by their irritation or pressure, excite a considerable 
amount of inflammation, or even of local obstruction to the cir- 
culation. 

We are not acquainted with any medicinal means of correcting 
those alterations of vital properties in the molecules or textures 
from which morbid growths take their rise. The same spon- 
taneous power which places these growths beyond the controlling 
influence of the laws of textural nutrition, places them beyond the 
reach of general remedies. The surgeon can in some instances 
remove the diseased part by the knife, and can sometimes further 
modify its properties by the direct application of escharotics or 
caustics, which destroy the morbid cells or germs which are the 
roots of the growth; and where this can be effectually done with- 
out serious injury to other living parts, the cure may be complete. 
It is doubtful whether the physician possesses any means of aid- 
ing the surgeon in these cases, or of controlling morbid growths 
which are beyond the reach of the surgeon, further than those 
calculated to promote the general health of the body. 

In many instances, the secondary pathological changes induced 
by morbid growths, such as inflammation, congestion, dropsy, 
flux, &c, are the chief objects of treatment, and may often receive 
much benefit from the usual remedies; but the extent of this 
benefit is commonly limited, as to extent and time, by the per- 
manency and intractability of the morbid growth, which is their 
cause. Thus, with encysted dropsy of the ovarium, peritonitis, 
ascites, and cedema, obstruction of the intestines, and other se- 
condary functional disturbances, generally admit of relief for a 
time; but as the ovarian tumour remains, and increases in spite 
of all remedies, the resulting disorders recur again and again, 
and at last prove fatal. But the growth of the cysts themselves, 
although generally progressive, is sometimes very capricious — 
being sometimes very rapid; in other instances, even in the same 
case, it may remain stationary for years. Nay, cases are not 
wanting, although rare, in which encysted tumours have alto- 
gether disappeared: as after the operation of tapping, or even 
spontaneously, by rupture, into some of tire natural cavities. But 
such instances, although they show a variety, exhibited by mor- 
bid growths, not to be forgotten in connection with prognosis as 
well as treatment, are to be considered rather as exceptional 
cases, than as those following the usual rule. 



MORBID GROWTHS MALIGNANT. 329 



SECTION VIII. 

MALIGNANT GROWTHS. 

579. Malignant groivths are distinctly organized structures, 
arising in various textures of the body, invading these textures 
with their own peculiar substance, and often appearing succes- 
sively or simultaneously in several parts of the body. They prove 
injurious, and eventually fatal, not merely by their bulk and posi- 
tion, (§569,) but also by the change of structure which they may 
induce in various organs; by the intractable ulcerations and 
fungous wounds to which they tend; and, lastly, by a wasting 
and deleterious influence which they seem to exercise on the 
whole functions and structures of the body. In all these points, 
the most malignant growths exhibit a character perfectly distinct 
from the more simple, harmless growths, hitherto described; but 
it must be observed, that the degree of malignancy varies very 
much in different cases, by one or more of the preceding charac- 
ters being absent, or not yet well developed; and consequently, 
that morbid growths or tumours are occasionally met with, which 
present a doubtful or intermediate character between non-malig- 
nant and malignant. 

580. The names cancer and carcinoma (from the supposed 
resemblance of the diseased structure to a crab, cancer, xapxwo;) 
have been long applied to the whole genus of malignant growths, 
which comprehends the following varieties: — Scirrhus; mam- 
mary, pancreatic, and solanoid sarcoma; encep haloid or me- 
dullary sarcoma; fungus hxmatodes; and colloid or gelatinous 
cancer. That these are all varieties of the same disease may be 
inferred from the fact, that they more or less resemble each other 
in the characters of malignancy above described; and that they 
frequently occur in the same subject, either simultaneously in 
different parts, or successively in the same part. Thus a person 
who has long been affected with scirrhus of the breast, often dies 
with medullary sarcoma in the liver or lungs; or after a scirrhous 
tumour has been removed from any external part, an encephaloid 
or fungous disease may subsequently appear in its place. The 
varieties may, for the most part, be traced to different degrees of 
activity in the specific or cancerous matter, that may now be 
stated to be the materies morbi, and to the varied changes in the 
new growth, ; i in I in the implicated textures which this matter, 
thus differently active, can produce. Of these varieties, il may 
be said generally, thai scirrhus, and perhaps the mammary and 
the pancreatic sarcoma, exhibits n chronic character, with less 
activity and tendency to increase locally or to spread through the 

28* 



330 STRUCTURAL DISEASES. 

system; whilst the others constitute the more acute forms of can- 
cer, causing more rapid growth in the parts first affected and 
more speedily appearing in other parts of the hody. 

581. The peculiar matter of cancer is distinctly a structure, 
consisting of nucleated cells and molecules, contained in an areolar 
or fibrous web of very various density. Of these, the cells must 
be considered the first elements; and although they present some 
variety in form, they are constantly found in every kind of can- 
cer. These cells are chiefly globular, and retain that shape in 
the soft, gelatinous kinds of cancer; but in others, many are can- 
date or spindle-shaped, as if in the process of transformation 
into fibres. In scirrhus, and other more solid and chronic forms 
of cancer, the fibrous structure is more abundant, and is very 
perceptible to the naked eye, forming glistening striae or bands 
radiating through the mass, of cartilaginous hardness; the can- 
cerous cells and numerous granules are seen between these fibres, 
and accompany them to their outermost branches. In the cere- 
briform or medullary kind of cancer, the nucleated cells are very 
numerous; and the texture in which they are contained is cellu- 
lar, and well supplied with vessels. This is the species in which 
the growth is most rapid, and in which, from the extravasation 
of blood in the loose new texture, a bloody aspect is given to 
parts of it, whence the name fungus htematodes. 

5S2. The intrinsic disposition to grow, even at the expense of 
the nutriment of other parts of the body, which was mentioned 
to be a character of some formations not distinctly malignant, 
(§ 574,) is exhibited in a much higher degree in malignant struc- 
tures, the increase of which may take place most rapidly when 
all the natural textures are wasting away. This fact again sug- 
gests the idea of an independent vitality possessed by these struc- 
tures, in virtue of which, like parasitic animals or plants, they 
luxuriate at the expense of the whole frame. The question next 
arises — Are these growths truly parasites, arising from ova or 
seeds derived from without the body, and after entering it, and 
finding a proper nidus or soil, taking root or becoming developed 
as a distinct being, like worms or hydatids, only drawing its 
nourishment from the fluids and solids of the body? If it be 
objected that malignant growths are too closely attached to, and 
too much identified Avith, the textures of the body to permit the 
notion of a distinctness of being, it may be replied, that cancerous 
cells, their most distinctive part, are often loose and unattached: 
they propagate themselves by the production of young cells 
within them; and it has been proved, by an experiment of Pro- 
fessor Langenbeck, that the cancerous pulp containing these cells 
is capable of propagating cancer in animals on being injected 
into their veins. This positively identifies cancer with contagious 



MORBID GROWTHS MALIGNANT. 331 

diseases, respecting the causes of which we formerly noticed 
questions like the present, as to their parasitic nature, (§ 99.) 
Contagion is not, however, a common cause of cancer; the only- 
example ever adduced being a rare one of the penis becoming 
infected by a carcinomatous os uteri. Further, it has been well 
remarked by Dr. W. Budd,* that the causes which have been 
supposed to induce cancer are not such as can, in any intelligible 
way, favour the introduction of germs from without the body. 
Thus, in chimney-sweeps and others, the continued application 
of soot has been observed to be followed by the occurrence of 
cancer in the scrotum, in such a number of cases, as to justify the 
inference that it has been the exciting cause. The often re- 
peated contact of a tobacco-pipe with the lip has also been con- 
sidered a cause of cancer of that part. But neither of these 
causes can, in any conceivable way, promote the development of 
cancer from extrinsic germs. 

The alternative that presents itself is, that cancerous growths 
may arise from a peculiar perversion of the natural nutritive 
process, similar to those modifications which we have been in- 
duced to suppose are the causes of the more peculiar kinds of 
common growths; but in the case of malignant disease, the perver- 
sion is much greater in degree, and shows itself, not only in its 
origin, but in its whole subsequent history. It can be conceived 
possible, that causes long acting locally, as the soot on the scrotum 
of chimney-sweepers, the tobacco-pipe on the lips of inveterate 
smokers, the irritations of the stomach connected with habitual 
dyspepsia, and of the uterus from irregular menstruation, &c, 
may induce this extraordinary alteration in the molecular nutri- 
tion of these parts; but we cannot hereby at all explain the pecu- 
liarity of this alteration, which must therefore be viewed as an 
ultimate fact in connection with nutrition. In other words, if we 
assume that cancer cells are modifications of the natural cell-germs 
by which textures are produced and nourished, we do not thereby 
explain (or refer to a known law) the extraordinary anomalies of 
the independent vital properties and consequent growth of these 
modified cells, which are obviously different from that of texture 
cells in general, and derive much of their destructive effects from 
such difference. It remains for future investigation to establish 
the law of that difference. We have before stated, that Dr. 
Ilodirkin has proposed a plausible hypothesis with regard to 
these and other growths, that they originate in cysts, (not cellsor 
microscopic cysts, but larger ones, which comprise these;) and 
thai the multiplication of these cysts within each other, their pro- 
longation Into radiated fibres, their pressure on adjoining textures, 

• Remarks on the Pathology and Causes of Cancer, Lancet, May 28, 1842. 



332 STRUCTURAL DISEASES. 

and consequent inflammation, induration, ulceration, atrophy, or 
gangrene of these textures, comprise the whole history of malig- 
nant growths. What appears to me to be chiefly wanting to 
establish Dr. Hodgkin's views is, a more distinct demonstration 
of the supposed cysts, which, at the commencement, or at the 
outer limits of cancerous growths during their spread, ought to be 
distinctly visible. 

583. But although the precise origin of malignant growths is 
still a matter of uncertainty, some important practical facts may 
be gathered from their pathology. Their microscopic structure 
and history pretty clearly show that they are of local origin; that 
they extend by the multiplication of their cells, which, by per- 
verting the nutrition of the adjacent parts, cause the growth of 
the tumour; that they ultimately infect other parts of the body, 
by spreading to the nearest lymphatic glands, and by the mixture 
of their cell-germs with the blood, (§ 259,) which form new 
tumours in the liver, lungs, or other vascular parts, (the same as 
those in which purulent deposits take place, and for similar rea- 
sons, § 470;) or the cancerous matter is sometimes found in clots 
within blood-vessels, or in the coagulable lymph effused by in- 
flammation.* 

But the history of malignant growths comprises not only that 
of the development of the cancerous structures in different de- 
grees and forms, but also their effect on the adjacent textures; and 
it seems to me possible, by a due regard to these two elements, to 
explain much of the varieties which cancerous disease presents. 
Thus scirrhus is the slowest form of the disease, because it gene- 
rally occurs in persons above the age of forty, in whom the tex- 
tural nutrition is tardy, and the cancerous matter is but slowly 
developed: the effect on the adjacent textures is to excite inflam- 
mation of a chronic form, and therefore leading to induration, and 
often to contraction, (§ 479,) and more or less obliteration of the 
natural textures. Hence the hard, knotty, corrugated swelling 
of scirrhus of the mamma, rectum, pylorus, &c, which may be 
attended with more or less pain of a peculiar stinging or lancinat- 
ing character, besides various functional disturbances, (obstruction 
to the passage of food or faeces, severe dyspepsia, vomiting, &c.) 
The continuance of irritation in the indurated parts leads (as usual) 
to ulceration, (§ 466.) This constitutes what is called open cancer, 
with ragged, inverted, or everted edges, and a fungous or sloughy 
interior, discharging a dark, offensive, ichorous matter. That 
such ulcers should be wholly incapable of healing is quite intelli- 

* In a case (which I lately saw with Mr. Avery) of malignant disease of the 
lungs and deep cervical glands, involving the 8th nerves, there had been recent 
pleurisy, and the bands of false membrane were glistening, and grated under the 
scalpel from the presence of cancerous fibres. 



MORBID GROWTHS MALIGNANT. 333 

gible, when it is remembered that its walls are composed of the 
cancerous structure and the compressed remains of the natural 
textures, whose secretions are too poor and too much perverted 
to afford euplastic secretion. The ulcer may prove an outlet for 
the increasing cancerous matter; and if the discharge be checked 
by external means, the disease is more likely to spread or to at- 
tack other parts: as the ulceration destroys the indurated mass, 
and thus removes the barrier between the cancerous germs and 
the healthy textures, there is greater chance of the body becoming 
more generally infected. Hence, too, from the multiplication and 
diffusion of the germs, the secondary malignant growths that may 
appear in other parts are often of the softer, more rapidly growing 
kinds. The influence of scirrhous cancer on the whole frame, 
although more slowly induced, perhaps for this very reason, is 
carried to a greater degree than that of any other form of cancer. 
Emaciation sometimes reaches a point unequalled in any other 
disease; and the wasting, of which this is the sign, extends to the 
composition as well as to the bulk of organs and textures. Thus 
bones lose much of their animal matter, and become so brittle, as 
sometimes to be fractured from the slightest violence. All mem- 
branes become extremely thin; the omentum often wastes away, 
excepting a few threads. The lungs exhibit a remarkable light- 
ness, in weight and colour; and 1 have seen the old cicatrices or 
consolidations, so frequently found at their summits, thinned and 
almost as pliant as other parts of the pulmonary texture.* But 
nothing is more remarkable than the exsanguine state of the 
textures generally; and this condition is obvious during life in an 
extreme pallidity, often associated with a sallowness or peculiar 
lemon-tint of complexion, that has been observed to be peculiar 
to cancerous subjects. 

Scirrhus chiefly occurs above the age of forty; and the more 
advanced the age, the slower generally is the progress of the dis- 
ease. It lias been remarked, by Sir Charles Bell, Sir Astley 

* It appears to me, that the rare coexistence of tubercle with cancer, as noticed 
by some writers, is to be ascribed to the former being removed by absorption, 
during the extraordinary wasting oftextures which attends chronic cancer. I have 
twice found, in the hodies of persons who died of cancer, considerable remains 
of tuberculous deposit at the apex of the lungs, without any tubercles in other 
parts. In one case, masses, partly caseous, partly calcareous, of the sizes of a 
pullet's and a pigeon's egg, were thus found encysted by a thin membrane. In 
another, a cavity communicating with the bronchi, taversed by a band of dense 
. iik'- that fonnd in tuberculous cavities, and lined with a thin, smooth 
membrane, was in the middle lobe. In all these cases, the other' parts of the 
lungs were free from tubercles. Now, It doe aot ;i|ipear probable that such 
[erable tuberculous deposit should have takui plan- without some in other 

parts ai-u. We meet with no case of recent tubercle thus limited to one portion 
of the lung. These and Bimilar facts connected with the emaciation of old 
in to me to fnrnish strong arguments in favour of the absorption of 
tubercles. 



334 STRUCTURAL DISEASES. 

Cooper, Mr. Travers, and others, that scirrhus of the breast, 
which will ran a comparatively rapid course at the age of forty- 
five, will remain stationary for years, and hardly appears to 
shorten life at the age of sixty or seventy. This shows the share 
which activity of textural nutrition has in causing the increase 
and dissemination of cancerous disease. It is under such circum- 
stances that operations for the removal of the disease have been 
most successful; but it must be remembered, also, that in such 
cases they are less strongly called for. 

5S4. The pancreatic, mammary, lardaceous, (or pork-like,) 
and solanoid, (or potato-like,) forms of cancer appear to be inter- 
mediate between scirrhus and encephaloid disease, increasing 
more rapidly than the former, yet approaching to it in firmness. 
They are attended with less pain, from the smaller degree of ten- 
sion and induration which they cause in the implicated textures. 
For the same reason, they are less disposed to ulcerate (§ 466) 
or slough, (§ 474;) and they commonly prove fatal, either by their 
growth and encroachment on some vital part, or by leading to 
the dissemination of cancerous deposits in other parts of the 
system. 

585. Encephaloid, (brain-like,) or medullary sarcoma, is the 
acute or rapid variety of cancerous growth. It occurs chiefly in 
young and middle-aged subjects, and in the most vascular tex- 
tures; and it may be fairly connected with the activity of their 
molecular nutrition. This may be the cause of the rapid increase 
of the cancer-germs or cells, (if these be indeed mere modifica- 
tions of the cell-germs of textures;) but much of the speedy 
growth and early dissemination of this variety of cancerous dis- 
ease, must be attributed to an active plastic process, which the 
presence of the cancerous matter excites in the vascular textures 
in which it lies. The mass of encephaloid tumours comprises 
false membranes, lymph, and even coagula of blood, in various 
degrees of organization: among and between these are found the 
cancerous cells, which luxuriate and rapidly multiply in so fertile 
a soil. It is in connection with tumours of tins kind that the fact 
before noticed has been observed, that coagula in the neighbour- 
ing veins have exhibited the encephaloid appearance; and so has 
coagulable lymph, produced by inflammation of serous mem- 
branes or parenchymata of organs. The speedily destructive in- 
fluence of this kind of cancer is- mainly to be ascribed to the rapid 
dissemination of the cancerous matter, and the bulky depositions 
which it induces around it, which, although organized, and highly 
vascular, are beyond the controlling influence of the powers of 
assimilation or absorption, and consequently stuff, obstruct, and 
compress organs to a fatal extent. The facility of growth in 
these tumours receives some explanation in the varicose condi- 



MORBID GROWTHS MALIGNANT. 335 

tion of their vessels, as ascertained by Mr. Kiernan, and their 
free communication with arteries, (§ 420,) as pointed out by 
Schroeder Van der Kolk. The same circumstance, together with 
the general softness and looseness of their texture, accounts for 
the facility with which haemorrhage takes place into their sub- 
stance, (§ 357,) causing an appearance that has led to the use of 
the term fungus hxmatodes. These forms of disease commonly 
prove fatal before the emaciating effects, so remarkable in scir- 
rhus, have advanced far. 

5S6. The colloid or gelatinous {areolar of Cruveiihier) va- 
riety of cancer seems to me to represent the cancerous element 
almost in a separate state, little mixed with natural tissues or their 
products. According to Miiller, it consists chiefly of cells con- 
tained in a very slight loose web; the cells are larger and rounder 
than usual, and contain small cells, which also contain cell-germs. 
The peculiar germinal principle of cancer is here, therefore, very 
abundant and prolific; but the nutritive secretion of the sur- 
rounding textures is not equally copious: therefore no distinct 
growths are formed; but the gelatinous matter is found infiltrated 
into the webs of textures, chiefly in connection with advanced 
stages of other forms of the disease. 

Further varieties have been described, by Dr. Carswell and 
others, according to the particular form which the cancerous 
growth assumes, such as the tuberiform, stratiform, rami form, 
&c. They are probably connected with the anatomical construc- 
tion of the parts in which they appear, together with the quantity 
and rapidity of development of the new growth. 

587. Another morbid production that has generally been class- 
ed among malignant growths, because it affects many textures 
and may supersede them, is melanosis, black cancer, or black 
tubercle. It most commonly occurs in the form of a loose cellular 
tissue filled with the peculiar black matter suspended in a serous 
liquid; but sometimes its substance is quite compact, and resem- 
bles crude yellow tubercle, or the lardaceous form of cancer. I 
have a drawing which I made of a lung exhibiting a combina- 
tion of encephaloid disease with melanotic tumours, the latter of 
Compacl texture, like nodules of pulmonary apoplexy, and vary- 
ing in colour from a dark bistre brown to a deep jet black. The 
combination of melanosis with carcinomatous tumours has also 
In ii i noticed by Cruveiihier and Carswell. Andral describes 
melanosis to occur m four forms: — " (l) It pretty frequently con- 
stitutes masses, encysted or otherwise; (2) the matter which 
composes it may, like the tubercular matter, be infiltrated into 
different tissues; (3) it may be spread like a layer, of greater or 
less thickness, on the free surface of membranous organs; (4) 



336 STRUCTURAL DISEASES. 

it may exist in the fluid state, either pure or mixed with other 
fluids."* 

The peculiar characteristic of all these forms is the black mat- 
ter, which, from the analyses of Dr. Fyfe, M. Thenard, and M. 
Foy, appears to be a highly carbonized insoluble matter, supposed 
to be altered colouring matter of the blood. It has been com- 
pared by Andral to the black pigment of the eye, and he con- 
siders it to be identical with the black matter commonly found in 
the lungs and bronchial glands. The colouring malter of the 
blood certainly is sometimes changed into a perfectly black mat- 
ter, as in the black vascular striae and patches in the intestinal 
canal, particularly in chronic inflammation, where the blood has 
been effused or retained in vessels, and altered by the intestinal 
secretions and gases. These black appearances are called by Dr. 
Carswell spurious melanosis. Again, the black pulmonary mat- 
ter is merely a carbonaceous powder contained in the interstices 
of the textures, and sometimes in the vessels of the lungs and 
bronchial glands; but whether it also proceeds from the colour- 
ing matter of the blood in an altered state, or is truly a deposit of 
carbon, is uncertain. All that is requisite to produce a black car- 
bonaceous deposit in the colouring matter of the blood is the 
abstraction of a certain amount of hydrogen, which the mineral 
acids are capable of effecting; and it seems not improbable that 
such a change takes place naturally in the formation of black pig- 
ment through the operation of peculiar cells, (pigment cells,) and 
as a result of disease in melanosis. 

But this production of black matter may coexist with various 
modifications of the nutritive process; plastic, as in cellular and 
membranous melanose tumours; cacoplastic, as in the hard black 
tubercle, and in the black consolidation of chronic pneumonia; 
and aplastic, as in the combination of black with opaque caseous 
matter, not unfrequently found in the lungs and bronchial glands. 
So, too, it may be, as we have seen, combined with various forms 
of malignant disease; but, with Andral, I hesitate to class simple 
melanosis with malignant growths. 

588. The treatment of malignant disease has been generally 
considered to belong rather to surgery than to medicine, and yet 
the utility of removing malignant growths by operation has been 
generally deprecated by surgeons down to the present time, when 
they may again learn, chiefly from the investigations of physicians, 
when and why operations may be expected to be successful. 
The indications of treatment which are suggested by the foregoing 
account of malignant disease may be summed up under three 

* " Pathological Anatomy," (Transl.,) vol. i. p. 249. 



MORBID GROWTHS MALIGNANT TREATMENT. 337 

heads: — (l)to extirpate the malignant growth; (2) to retard its 
development; and (3) to counteract its effects. 

The complete extirpation of malignant growths can be effected 
only when they are quite local, so that when removed by the 
knife or by caustic, no root nor stray germs of the disease shall 
be left behind. We have adduced reasons to suppose that at its 
first origin cancer is entirely local, and that if it be completely 
excised at. an early period, a cure may be effected. For this 
success, it is essential that every cancerous cell be removed; and 
Dr. Hodgkin has recommended the careful examination of the 
portion removed, to see that it contains on its surface none of 
those grains consisting of an aggregation of cancerous cells, 
which can be seen even with the naked eye in cancerous struc- 
ture. Dr. W. Budd recommends the use of the microscope for 
the same purpose: " If the characteristic cells were found on the 
cut surface of the portion removed, it would be morally certain 
that others have been left behind, and that the extirpation is in- 
complete, although, on the other hand, the absence of these cells 
would be by no means so sure a guarantee of their entire removal. 
Such an examination would, however, always be a matter of 
great interest to the surgeon."* The best security would lie in 
the operation being performed before the constitution has been 
in any degree impaired by the disease; and particularly before 
any neighbouring parts, especially lymphatic glands, have shown 
any indications of disease. The best chance will therefore be 
afforded in cases in which the growth is most chronic and in- 
active, and of the smallest extent, as in scirrhus of the lip, skin, 
or breast. If any cancerous texture or germs are left behind, the 
operation is likely to do harm instead of good, by bringing them 
into activity, and developing the acute form of the disease. 
Cases have occurred in which a cancerous breast has been com- 
pletely removed by a spontaneous sloughing; but such an event 
is extremely rare. Cauterization is less advisable than excision, 
being less manageable. 

589. The second indication, to retard the development of the 
malignant growth, is chiefly to be attempted by means which 
diminish the circulation through the diseased part. Repeated 
local bleedings have been found useful, partly perhaps in this 
way, but more by relieving the inflammation excited by the 
growth. The best means for staying the growth of malignant 
disease is by pressure, which has long had many advocates. 
Such b kind and degree of pressure, as will reduce the circulation 
through the part to the lowest degree compatible with its life, 
will pretty surely arrest the increase of the morbid growth, by 

• Lancet, May, 1842. 
29 



33S STRUCTURAL DISEASES. 

depriving it of its nutriment. But for the utility of this measure 
it is equally necessary that the disease shall not have extended 
to other parts besides those to which the pressure is applied, 
otherwise in those parts, which are commonly internal, the 
growth will proceed with an increased rapidity, proportioned to 
its suspension by the pressure on the outward part. The best 
means of applying pressure are those contrived by Dr. Arnott, 
especially the slack air-cushion under a compress. It is very 
doubtful that we possess any means of influencing malignant 
growths through the constitution. Various medicines have en- 
joyed an ephemeral repute for their efficacy in cancer. Of these, 
conium has been one of the most favourite. Dr. A. T. Thomson 
considers the iodide of arsenic to possess some power in control- 
ling the increase of cancers. But it is doubtful that any of these 
remedies do more than soothe irritation, and restrain common in- 
flammation and its results, with which malignant growths are 
generally complicated. 

590. The third indication, to counteract the effects of morbid 
growths, is more commonly the object of treatment; but the 
means of fulfilling it fail more and more as the disease advances. 
The use of narcotics of every description, general and local, to 
soothe the pain and irritation, and of occasional local antiphlo- 
gistic measures to remove inflammation and congestion, is com- 
monly admitted in palliation of malignant disease; but the im- 
portance of tonics and nutritive diet to counteract the increasing 
cachexy and emaciation is not so generally regarded. Yet these 
have appeared to me to have considerable efficacy in supporting 
the constitution and supplying it with strength against the enemy 
that is preying on its vitals. Preparations of iron, when borne, 
are the best tonics. 



SECTION IX. 

DISORDERS OF MECHANISM. 

591. Many structural diseases arise from changes in the me- 
chanism of organs, which are not precisely implied in any of the 
preceding elements. It is quite needless to enter into a detail of 
these alterations of mechanism; but to complete our key to the 
elements of disease it will suffice to cite a few examples. 

Hollow organs are liable to dilatation from an undue accumu- 
lation of matter within them. Thus the heart, arteries, and 
veins, the air-cells of the lungs, portions of the intestinal tube, 
the bladder, &c, become distended when there is an obstruction 
to the passage of their respective contents, or when the expulsive 



DISORDERS OF MECHANISM. 339 

power by which they are contracted is weakened; and such dis- 
tension, if long continued or frequently repeated, becomes a per- 
manent dilatation. 

Parts may become overstretched and relaxed by a loss of na- 
tural cohesion or elasticity; thus, ligaments, tendons, and fasciae, 
become relaxed and ineffectual in binding together or connecting 
the parts to which they are attached. 

592. Contraction is the opposite of dilatation. It may consti- 
tute stricture, and lead to the partial or total obstruction of parts 
of the canals of the intestines, urinary and respiratory apparatus, 
vascular systems, &c. The influence of contraction of the texture 
of organs and of serous membranes, we have several times had 
occasion to notice as the results of disease. 

593. Parts may be ruptured or lacerated, either from previous 
disease or from violence, and structural disease is the result. 
Thus, hollow organs, the heart or arteries, the stomach, the gall 
bladder, the urinary bladder, have been ruptured with speedily 
fatal results. Rupture of the valves of the heart, of portions of 
blood-vessels, of air-cells, &c, injures the mechanism of these 
parts, and forms an element of structural disease. 

594. Displacements and compressions of organs are frequently 
the effect of tumours or effusions, as in the case of the tumour of 
ascites, or ovarian dropsy, or an enlarged liver, pushing up the 
heart and lungs, and variously compressing and displacing the 
abdominal viscera; of an enlarged heart or aneurism displacing 
and compressing the lungs and air-tubes; effusions in a pleural 
sac, compressing the lung of that side, and displacing the heart, 
mediastinum, diaphragm, liver, and the walls of the chest. 

595. Contortion of rigid parts is exemplified in rickets, mol- 
litiea ossium, and rheumatic nodosities of the joints. Curvature 
of the spine, besides shortening the length of the trunk, disorders 
also the mechanism of respiration, by changing the position of 
the ribs; and when the distortion is great, the function of the 
hearl and greal arteries, and of the abdominal viscera, may like- 
wise be affected by it 



CHAPTER V. 



THE CLASSIFICATION, SYMPTOMS, AND DISTINCTION 
OF DISEASES. 



SECTION I. 

NOSOLOGY. 

596. Having considered the causes of disease, their mode of 
operation, the resulting effects on function and structure in the 
ultimate and proximate elements of disease, and the remedial in- 
fluences which can be brought to remove or counteract these ele- 
ments; we have next to notice the manner in which these elements 
of disease affect the several parts and functions of the body, the 
symptoms which they induce, and the combination or forms 
which they present, as special diseases. In order thus to allot 
together in distinct divisions the wide domain of disease that has 
been displayed by general pathology, it is necessary to define 
special diseases — that is, to designate their peculiarities by short 
descriptions, and to group and subdivide them in classes, orders, 
genera, and species. This classification and definition of diseases 
is usually implied by the word Nosology. 

597. Diseases may be classed in different ways. The first 
method attempted was a classification according- to their most 
prominent phenomena or symptoms. Of this kind was the 
system of Sauvage, who divided diseases into ten classes: — vitia, 
febres, phlegmasia;, spasmi, anhelationes, debilitates, dolores, 
vesanix, fluxus, cachexias. The classifications of Linnaeus, 
Vogel, and Sagar, were also of this kind, which may be termed 
artificial; and Cullen's division was a strained simplification of the 
same description of arrangement, condensing all diseases into the 
four classes: — pyrexia;, neuroses, cachexias, and locales. 

The chief objection to this, which may be called symptomatic 
nosology, is, that it regards symptoms as the essence of diseases, 
whereas they are really extremely variable, both in their kind 
and severity, and by no means uniformly correspond with the 



METHODS OF CLASSING DISEASES. 341 

nature or with the amount of the real change of function and 
structure present. Hence, too, similar symptoms, from the most 
diverse causes, are classed together, although they may require 
quite opposite plans of treatment; whilst diseases that are really 
kindred in their nature, are widely separated, because they differ 
in their symptoms. The artificial method of classification is ad- 
missible only as a provisional means of arranging subjects in a 
conventional way, until the true nature of these subjects is inves- 
tigated; when this is done, or even as it advances, the artificial 
method should give place to the natural one, which is not a mere 
glossary of names, (or symptoms,) but in itself expresses the most 
important points of knowledge of the nature of the subject. 

598. The true foundation of a natural classification of diseases 
is in a correct pathology, or knowledge of the intimate nature of 
diseases; but the subdivisions are conveniently determined by the 
chief seat of the disease, or by other of its more prominent cha- 
racters. The classification of Pinel approaches to this standard, 
although it is necessarily imperfect from the infant state of patho- 
logy at his period. He divided diseases into five classes: — -fevers, 
inflammations, haemorrhages, neuroses, and organic affec- 
tions. 

Pathology may be applied to the classification of diseases in 
two modes. In one, it is the first step in the arrangement, all 
diseases being distributed in classes expressive of the several pa- 
thological elements affecting the systems defined by general ana- 
tomy. Thus, according to the groups of pathological elements 
which we have reviewed, the classes might be— diseases of the 
muscular system, those of the nervous system, of the secernent 
system, of the blood, of the vascular system, and of nutrition. 
The subdivision of these classes into orders would be determined 
by the individual pathological elements: thus, diseases of the 
muscular system would be divided into those of irritability and 
those of tonicity, with the generic subdivision according to excess, 
defect, 01 perversion; and, lastly, the specific distinctions would 
be made according to the organ or locality affected. This ar- 
rangement is not suitable for clinical or practical purposes, because 
diseases are generally too compound to admit of being classified 
according to their elements: they commonly comprise several pa- 
thological elements, and the proportions of these elements vary 
with the progress of the case. 

599. The other mode of using pathology in nosology, is by 
making it subservient to establish those divisions or subdivisions 
in winch the character of the elements of diseases affords an 
obvious and natural mean of distinction, which may be useful in 
their diagnosis and treatment, whilst the remaining divisions are 
derived from the situation 01 other circumstances of the diseases. 

89* 



342 NOSOLOGY. 

Thus diseases may be classed according to their chief locality, the 
organ or set of organs which they affect. Thus, as classes of 
disease, we may have, diseases of the organs of respiration; dis- 
eases of the organs of circulation; of the apparatus of aliment- 
ation; of that of -urinary excretion and of generation; of the 
nervous system; of the organs of locomotion; of the skin; of the 
blood; and lastly, general diseases, having no denned seat. The 
division of these classes into orders is founded on pathology: thus, 
each class comprehends functional diseases, subdivided into dis- 
eases oiirr it ability, tonicity, sensibility, &c, and secretion; and 
inflammatory and congestive diseases; and diseases of nutrition, 
(structural.) A further division into genera and species is made 
according to the anatomy of the parts: thus, of the class, — dis- 
eases of the organs of respiration; order, functional disorders; 
genus, irritability — the species would be spasm ox paralysis of 
the larynx, of the bronchi, &c. But in general diseases, the sub- 
divisions must be altogether pathological, or founded on causes 
or symptoms: thus, fevers are distinguished into inflammatory , 
eruptive, adynamic, or contagious and malariouSjOT intermit- 
tent and continued, as each of these modes of distinction becomes 
most available. 

This last classification, although it may be less pure and me- 
thodical than others, is the most useful in practice, because it 
most closely follows nature; and, setting aside more minute and 
difficult distinctions, it leads to the seat and nature of the disease, 
and renders available those general principles in pathology and 
therapeutics which form the foundation of rational medicine. A 
chief recommendatien of this kind of nosology, or arrangement 
of individual diseases, is, that whilst it includes all diseases hitherto 
distinguished, it points out others which may and do occur, but for 
want of distinct pathological views and names have been con- 
founded with others more prominently defined. 

600. The definitions by which individual diseases are desig- 
nated may refer either to the pathological nature of the disease or 
to its characteristic symptoms, or to both, and in some instances, 
the causes or results of the disease form a characteristic part of 
its history. It should be remembered that the great purpose of 
nosology is to arrange and define diseases in such a manner that 
their true nature, with the chief points of affinity and difference 
between each other, may be expressed by the arrangement and 
definition; and whether these points of affinity or difference are 
most manifest in the causes, nature, or symptoms of the diseases, 
the arrangement and definition should duly regard them. Thus, 
besides its chief peculiar symptoms, the definition of a distinctly 
infectious disease, as scarlatina, should express its infectious 
character; that of a disease indubitably caused by marsh mias- 



SEMEIOLOGY AND DIAGNOSIS. 343 

mata, as ague, should imply this fact; whilst, by both being classed 
as general diseases, and in the order fevers, the one of the genus 
eruptive, the other of the genus intermittent, much of the na- 
ture of the diseases, as well as of their distinguishing characters, 
will be set forth by this nosological arrangement. The further 
that our knowledge of pathology is advanced, the more consider- 
able a part will it form in our nosological systems; but in the 
meantime it is better to render our classification and definitions 
as useful as possible by deriving them from all the most available 
sources of information, than to keep them imperfect and inappli- 
cable until science is sufficiently advanced to supply us with a 
system that is quite pure. 

As we do not enter upon special pathology, or the history of 
individual diseases, it is unnecessary to proceed into the details 
of nosology. The foregoing remarks are intended merely to ex- 
plain the objects of nosology, and to introduce the two associated 
subjects, semeiology and diagnosis. 



SECTION II. 

SEMEIOLOGY AND DIAGNOSIS. 

601. Semeiology treats of signs* and in medicine, of the signs 
of disease. The word symptom is commonly used in the same 
sense as sign; but, as its etymology implies,! it is a more vague 
expression, signifying coincidence or co-occurrence rather than a 
direct or constant connection. It has been attempted by some 
writers, (particularly French,) to restrict the word symptom to 
the phenomena manifested by present disease only; but this is 
contrary to the usual custom by which we speak of precursory 
and consecutive symptoms, symptoms of health, &c. Again, 
some have confined the term symptom to the phenomena de- 
pend ing on vital properties, whilst those phenomena of disease 
which are more directly physical they call signs. This was the 
sense in which Laennec used these words, and others have fol- 
lowed his example. Although this acceptation of the word is not 
in strict accordance with former usage or with their etymology, 
yet it would l>" convenient for conventional use; and to render 
it more precise, it will he well to prefix the epithets vital and 
physical, bs first suggested by Bayle, and partially adopted by 
Laennec. 

Lei us tin n understand the word sign of disease generally to 

• "Sign, that by which any thin?, is known." — Johnson':- Dictionary. 
f ivixTTTu/Aa, from<ruv, with, ami m<a», to tail. 



344 SYMPTOMS AND SIGNS OF DISEASE. 

imply, any thing by which the presence of disease may be made 
known. A symptom is any phenomenon which becomes obvious 
in the course of disease; it may thus often prove to be a sign; but 
many symptoms are of such uncertain connection with a parti- 
cular disease, that they cannot be said to make known the pre- 
sence of a disease, and therefore they cannot be called signs. 
The more specific designation of physical signs and vital symp- 
toms will succeed better in attaching a distinct meaning to the 
different phenomena of disease; and by stating briefly the grounds 
of this distinction and the proper application of the terms, we may 
be able to point out the respective value of each class of pheno- 
mena to which they are properly applied. 

602. Physical signs are those physical properties of the body, 
or of a part of it, which are perceptible to any of the senses of 
the observer. Thus, the form, size, colour, firmness, or softness, 
weight, heat, and odour, of the whole body, may be said to give 
physical signs or evidence of its condition, whether in health or 
in disease. So, also, the form, size, colour, resistance, position, 
temperature, smell, and acoustic properties of a part of the body, 
afford physical signs of its condition, whether in health or in dis- 
ease. Thus, the appearance of an external disease, the feeling 
of a solid tumour, or of the fluctuation of liquid in the abdomen, 
listening to sounds produced by or in diseased internal parts, fur- 
nish us with physical signs of the presence of disease. 

The difference between the signs of health and the signs of 
disease is determined by our knowledge of what is usual in health, 
and this knowledge may be derived (f )from general observation 
or experience of healthy standards, or (2) from anatomical and 
physiological knowledge of what the phenomena of health ought 
to be; or (3) from a particular knowledge of the standard of 
health in any individual case. 

All of these healthy standards of comparision are available: 
the first is less exact than the other two; but it is often available 
for obvious disease. Thus, a jaundiced hue of the body, extreme 
pallor, or great emaciation, afford to the common observer phy- 
sical signs of disease which cannot be mistaken. But slighter 
degrees of the same signs may become manifest only to those 
who, by previous acquaintance, know more exactly the standard 
of health in the individual, and can distinguish a change in 
colour or in flesh from that standard. Again, in local disease: a 
large tumour or swelling in a part is a sign of disease obvious to 
every one; but a smaller or more deep-seated tumour may be 
discovered only by those who have an accurate knowledge of 
the healthy anatomy of the part, or by those who by previous 
observation have made themselves familiar with the shape and 
feel of the part in health. 



METHODS OP DETECTING SIGNS. 345 

603. Another standard available to distinguish the physical 
signs of disease from those of health is a comparison of parts 
that are naturally symmetrical. Thus, a slight swelling in one 
limb may be readily discovered by comparing it with the corre- 
sponding part of the opposite limb. A projection or contraction 
of one side of the chest may escape observation until the two 
sides are compared by inspection or by measurement, which will 
detect the difference between parts that are naturally alike. This 
standard of symmetrical comparison is applicable, not only to all 
external parts and to organs of animal life, but also to some in- 
ternal parts, which, although not strictly symmetrical, are so far 
equally distributed on the two sides as to give symmetrical pro- 
perties to the exterior. Thus, the lungs, in health, fall so equally 
on both sides of the chest, that they give corresponding motion 
and acoustic properties to both; and percussion or respiration 
yields similar signs on both sides. So, when disease affects one 
side, it changes its physical signs, and their difference becomes 
obvious by comparison with the signs of the healthy side. A 
certain degree of uniformity also results from the position of the 
viscera in the abdomen, so "that (making allowance for the greater 
bulk of the liver on the right side) any considerable difference in 
the shape or resistance of the two sides may be interpreted to be 
a sign of disease. 

604. For organs which are not symmetrically placed, previous 
knowledge of their natural structure, position, and physical pro- 
perties, is necessary. Thus, we cannot know the physical signs 
of diseases of the heart and liver, without having a healthy stand- 
ard to compare them with. This standard is soon supplied by 
the observation of the signs in health, and our knowledge of it 
may be much assisted by a familiar acquaintance with anatomy 
and physiology, which teach the healthy condition and functions. 
Thus, anatomy teaches us that the heart lies behind the lower 
half of the sternum and the adjoining parts of the cartilages of 
thf lefl ribs from the third to the sixth; and physiology makes us 
acquainted with its regular double sound heard in this region: 
these furnish a healthy standard, and when we compare it with 
a case in which the impulse of the heart is felt to beat over a 
much wider space, and the sounds are irregular and masked by 
grating or blowing murmurs, we at once discern these phenomena 
to be signs of disease. Again, anatomy informs us that the liver 
in a healthy adult extends little, if at all, below the margins of 
the ribs mi thr right side; and the knowledge of this fact points 
nut as a sign of disease such dullness on percussion and resistance 

Id i in 'ssi i re Ik 'low these ribs as ;i rise from the liver teaching much 

below its usual situation. The knowledge of the bealthy me- 
chanism and functions of the apparatus of respiration, circular 



346 SYMPTOMS AND SIGNS OP DISEASE. 

tion, digestion, and excretion, is in many respects necessary to 
enable us to distinguish the signs of disease from those of health; 
it will guide us to refer the signs to their true causes; and it may 
often suggest the particular signs which may be expected to arise 
from a particular lesion. 

605. Physical signs are phenomena taking place in the body, 
in accordance with physical laws. It is therefore obvious, that 
a knowledge of these laws, as well as of the mechanism of the 
body, will assist us to interpret these phenomena; to explain of 
what they are signs, how they are caused, the variations which 
they may present, and the best mode of appreciating them. Thus 
an aneurism of the arch of the aorta may be chiefly detected and 
studied through the physical signs which it produces. It forms a 
tumour under or near the top of the sternum, pulsating in a dis- 
tinct manner, and with a peculiar sound; this tumour may press 
on the air-tubes in such a way as to alter their shape, and by 
partially obstructing the passage of the air through them, may 
also change the sound of breathing in a particular way: by com- 
pressing the veins, it may also throw their current into unusal 
sonorous vibration; or by a more complete obstruction, it may 
cause the veins to swell in a remarkable degree above the tumour: 
by its enlargement, the aneurism encroaches on the lungs, the 
walls of the chest, the muscles, nerves, bones, ligaments, &c, in 
such a way, as to alter their physical properties and positions, 
and thus to produce various physical signs. Now, all these 
physical signs are phenomena produced in the altered mechanism, 
according to certain laws; and it is plain, that a knowledge of 
these laws must greatly assist us to understand the signs, and to 
trace them to their true causes. Nay, even the aneurysmal tu- 
mour itself, in its production, increase, and intrinsic signs, can be 
rightly understood only through a knowledge of hydraulics and 
dynamics, in connection with the structure of the heart and arte- 
ries in health and disease. 

606. Vital symptoms are those phenomena which depend on 
vital properties of a part or parts of the body. Thus irritability, 
tonicity, sensibility, excitomotion, secretion, and the more com- 
plex functions resulting from combinations of these elementary 
vital properties, (§ 104,) in a natural state, produce the symp- 
toms of health; in an altered state, constitute the symptoms of 
disease. Hence vital symptoms have also been called functional 
symptoms, and physiological; but both these terms are objec- 
tionable, because both, function and physiology relate likewise to 
physical properties, and would, therefore, include physical signs. 
Vital symptoms are often less confined to a part than physical 
signs; because the vital properties of the whole system are in 
general connection; thus the irritability of the heart spreads its 



VITAL SYMPTOMS NAMES AND CHARACTERS. 347 

influence throughout the vascular system, the sensibility of one 
part affects the nervous centres, and may produce sympathetic 
symptoms in other parts, (§ 156;) disordered secretion has effects 
on other parts, (§ 162 — 7, &e.;) so that vital symptoms are often 
generally distributed throughout the body. For this reason, they 
have been sometimes called general symptoms, to distinguish 
them from physical signs, which are chiefly local; but this appel- 
lation is not exact, inasmuch as vital symptoms are sometimes 
entirely local: as in the case of pain, spasm, &c; and we have 
already mentioned, that physical signs are sometimes quite gene- 
ral throughout the body, as those of the yellowness of the whole 
surface in jaundice, the swelling of the body in dropsy, &c. 

Vital symptoms are sometimes called rational, because (I pre- 
sume) their connection with their cause is rather a matter of in- 
ference than of direct observation: but this is the most absurd 
term of all; for observation is necessary to teach us the value as 
much of symptoms as of physical signs; and physical signs are 
of little use without a proper exercise of reason upon them. 

607. Vital symptoms may be exemplified in pain, uneasiness, 
altered and impaired sensations, which arise respectively from 
exalted, perverted, or defective sensibility, (§ 125 — 136;) in spasm 
and paralysis, which proceed from excessive or defective con- 
tractility, (§ 110 — US,) or excitomotory power, (§ 139 — 154;) in 
cough, which is caused by irritation or undue excitability of the 
excitomotory nerves of the air-passages and muscles of expira- 
tion; in vomiting, which depends on irritation or undue excita- 
bility of the stomach and the excitomotory nerves sympathetically 
allied with it; in dyspnoea, which arises from a feeling of want 
of breath, (§ 231;) in fever, which comprises an accelerated pulse, 
hot skin, diminished secretions, &c. (§ 437.) 

Symptoms may further be found in the state of the different 
bodily functions in which vital properties are concerned. Thus 
the state of the pulse is an important source of symptoms: a 
frequent or a slow pulse indicates an increased or deficient ex- 
citement or irritability of the heart, (§ 113, 117;) a strong or 
weak pulse implies an increased or diminished strength of the 
heart's contractions, (§ 112, 116.) A hard or sharp pulse is in 
part dependent on an increased tonicity of the arteries, (§ 121;) 
whilst a soft, compressihlc, or liquid pulse, depends on a diminu- 
tion of this property, (§ 123.) Irregularity in the rhythm of the 
pulse arises from an alteration in the vita] property of irritability 
in the heart, commonly connected with loss of strength. These 
various conditions of the pulse are sometimes the result of various 
diseases directly affecting the vital properties of the heart and 

arteries themselves; bul i e commonly they are induced by 

diseases of other parts, sympathetically or through the blood in- 



348 SYMPTOMS AND SIGNS OF DISEASE. 

fluencing these organs, as in inflammatory fever, (§ 437.) Thus, 
in diseases of the heart and arteries, the pulse has more of the 
character of a physical sign; whilst in other disorders, it is rather 
a vital symptom, depending on further vital properties. 

The state of the skin is another source of symptoms chiefly 
connected with the vital properties of the superficial vessels and 
secernent apparatus, and of the general circulation. Thus the 
heat and dryness of the skin in fever arise from accelerated cir- 
culation with diminished perspiration. When the skin is cold, 
the circulation is weak; when warm, it is active; and the occa- 
sional occurrence of perspiration in both these conditions shows 
that another vital property, that of secretion, is concerned in 
causing the symptoms, dryness and moisture of the skin. The 
signs furnished by the skin are physical, so far as regards the 
condition of the skin itself; but they are vital symptoms in rela- 
tion to the state of the circulation, of distant organs, or of the 
system at large. 

Many important symptoms may be derived from the appear- 
ances of the tongue. These appearances, when arising from 
primary disease in the tongue itself, may be considered as phy- 
sical signs of its condition. Thus, when the tongue is inflamed, 
it is first red and swollen, and afterwards becomes covered with 
a film of fur, which, separating in patches, leaves the surface red, 
and smoother than before. But in a great many diseases, the 
tongue becomes red, swollen, furred, or brown and dry, from 
causes acting through the system; and these secondary affections 
of the tongue constitute symptoms of these diseases. The con- 
nection between febrile and other general diseases, and the ap- 
pearances which they produce in the tongue, is not well under- 
stood; but it probably depends on changes in the secretion of the 
mucous membrane covering the tongue and adjoining parts. 

[The state of the tongue has always attracted attention; and 
although the importance of the signs which it furnishes have 
been exaggerated, they are interesting and valuable. The tongue 
in disease is to be studied in connection with its modifications in 
volume, form, movements, colour, degree of moisture, nature of its 
coatings, its temperature and sensibility. Diminution in the size 
of the tongue is a frequent symptom in typhus and other low fevers; 
it is at the same time generally trembling and dry, conditions of 
equal gravity. A pointed, conical tongue was once supposed 
sufficient to establish the existence of gastritis. Experience has 
shown, however, that it indicates neither the nature nor the seat 
of the disease, or its danger, and that it depends entirely on the 
manner of contraction of the muscles of the organ. Impeded 
movement and distortion are valuable as unfavourable signs in 
fevers as well as in cerebral disease. In paralysis the deviation is 



SOURCE OF SYMPTOMS. 349 

usually more apparent than real; its seat being the buccal com- 
missure and not the tongue. When the tongue presents on its 
upper surface a coating, it is generally evidence of some morbid 
condition. Fasting will, in some persons, produce a white fur, 
and others who sleep with their mouth open are liable on waking, 
to have the tongue dry and dirty. Does the tongue faithfully 
represent the state of the stomach? The result of careful and 
repeated observations on the part of Dr. Louis indicate on the 
contrary, a great degree of independence of the conditions of the 
tongue and stomach. His observations, confirmed by others, 
show that the aspect of the tongue bears no relation whatever 
to that of the stomach; the same state which coincides at one 
time with decided disease of the stomach, occurs at others where 
this organ is healthy. Albuminous exudation on the surface of 
the tongue is unconnected with any particular state of the stomach, 
but is a phenomenon of singularly bad augury, as it rarely appears 
until a few days before death. It occurred in one-eighth of the 
cases of phthisis observed by Dr. Louis. — C] 

The alvine excretions furnish symptoms of great importance in 
various diseases. When excessive in quantity, liquidity, and fre- 
quency, they constitute diarrhoea, which may be primary — that 
is, a disease in itself, (§ 374;) or secondary, and, therefore, a 
symptom of disease, as in cholera and mucous enteritis. As a 
symptom, it presents further varieties in its character, whether 
faeculent, bilious, mucous, watery, &c. ; and these varieties indi- 
cate respectively, accumulation of faeces, or excessive secretion of 
bile, mucus, or watery fluid, in the intestines. The opposite 
condition, that of costiveness, is also a disease itself, and an im- 
portant symptom in many diseases, indicating defective peristaltic 
action, defective secretions, or both, in the intestinal tube. The 
quality of the evacuation supplies symptoms in regard to colour, 
shape, odour, &c, which often lead to a knowledge of the nature 
of disorder in the alimentary canal or in the system. Thus clay- 
coloured focces indicate defective secretion from the liver; those 
very dark in colour may denote the presence of diseased bile or 
altered blood; vermiform motions may indicate stricture or con 
traction of the intestines; and so forth. 

The urinary excretion is a valuable source of symptoms, not 
only of diseases of the pints connected with it, but of disorders of 
Other organs, and of the whole system. IJeiiiij; flic chief emunctory 
through which foreign, effete, and superfluous matters are elimi- 
nated from the blood, (§ 254,) it is continually exhibiting changes 
in quantity and quality, in colour and specific gravity, in iis sedi- 
ments, and in the effeel on it of dilTerenl chemical re-agents. All 
these changes furnish symptoms of disease, several of which have 
been already noticed in connection with various pathological 
30 



350 SYMPTOMS AND SIGNS OF DISEASE. 

elements, (§ 167, 176, 249, 254, 255, 257, 260, 309, 384, 385,' 
448, &c.) 

608. The foregoing examples of sources of symptoms are given 
merely to illustrate where and how symptoms are to be sought 
for; to complete the list, it would be necessary to notice every 
function of every part of the body, and the symptoms which they 
furnish, which would fill a considerable volume. 

As a knowledge of the mechanism of organs, in health and in 
disease, and of the physical laws which operate in them, is the 
best aid to the study of physical signs, so an accurate acquaintance 
with the structure and functions of the healthy and diseased body, 
and with the vital laws which influence them, is the best guide 
to the knowledge and explanation of vital symptoms. These 
symptoms are often obscure and unintelligible; because physiology 
and pathology is imperfect; but in proportion as these sciences are 
advanced, their application to semeiology and diagnosis will be 
more complete. In the meantime, much of our knowledge of 
symptoms rests chiefly on mere experience; and until the results 
of experience can be arranged in a more scientific manner, they 
may be parcelled numerically, in order to approach their laws by 
empirical means. But to render this statistical or numerical 
method of studying symptoms at all safe, it is necessary that the 
numbers of observations should be very large, that they should 
be applied to similar cases, and that the majorities which estab- 
lish the rule should very greatly preponderate over the exceptions. 

609. Physical signs and vital symptoms respectively have their 
value in making known the nature and extent of disease. Phy- 
sical signs are more certain, because they appeal more directly 
from the seat of disease to the senses; depending on simpler and 
more constant causes, physical properties, they are more constant, 
and less subject to variation than vital symptoms, which result 
from more complex, and therefore more variable, vital properties. 
Thus of the signs of inflammation, the redness, heat, and swelling, 
are physical signs, and more certainly prove the existence of in- 
flammation than does pain, which is a symptom depending on 
the vital property, sensibility, and which may be present where 
inflammation does not exist, (§ 136;) and may fail to occur when 
inflammation is present, (§ 433.) The physical signs of a struc- 
tural disease in the lungs or heart are better evidence of its exist- 
ence, and of its nature, than cough, dyspnoea, pain, palpitation, 
&c; because we know that these symptoms may arise from 
merely nervous or other causes,without the presence of any altera- 
tion of structure. Yet vital symptoms, although less sure and 
constant, than physical signs, are often more delicate, being pre- 
sent before physical changes become appreciable; and when they 
coexist with physical signs, they indicate the nature and amount 



FURTHER DIVISIONS OF SYMPTOMS. 351 

of disorder of the vital properties of the part, and of the whole 
system. Thus feelings of chilliness and discomfort, which usher 
in the fever accompanying tonsillitis, are sometimes present before 
the throat exhibits the physical signs of inflammation. A slight 
cough is often present in the early stage of phthisis, before the 
physical signs of tubercles can be distinguished. Crepitation heard 
in the posterior regions of the chest is a physical sign of engorge- 
ment of the lung with liquid in the minute tubes; but we must 
refer to the vital symptoms to determine whether the engorge- 
ment is inflammatory or only congestive. The physical signs of 
consolidation of the lung, and of valvular disease of the heart, 
are very distinct; but in order to determine whether these affec- 
tions have arisen from present or recent inflammation, or are the 
results of old disease, it is necessary to consult the vital symptoms; 
and this determination is of great importance to the prognosis and 
treatment. 

In short, it is obvious that both classes of signs ought to be 
carefully taken into account; and the more fully the physical and 
vital properties which constitute them are understood, the more 
available will signs and symptoms be to instruct us as to the na- 
ture and treatment of disease. 

610. Besides into physical and vital, various divisions of symp- 
toms have been made; but they are of little real utility, and it is 
unnecessary to do more than enumerate them. Symptoms are 
local, or general, or constitutional, according to whether they 
are confined to the diseased part, or affect more or less the whole 
system. Symptoms are idiopathic, when directly proceeding 
from a primary disease; they are sympathetic, or secondary, 
when arising from secondary disorders, or those produced by the 
primary disease. Premonitory or precursory symptoms are 
those which precede the full development of disease, and com- 
monly result from the first operation of its cause; hence they are 
called symptomata causae. Commemorative symptoms are those 
developed in the previous history of the disease. Jlnamnxstic 
are those' which relate to the previous state of health. Signs have 
been divided into objective, those which present themselves to 
the scrutiny of the practitioner; and the subjective, those described 
by the patienl himself. The objective have been further divided 
into the active or dynamical, those that require some action or 
motion of the patienl to discover them; and the passive ox statical, 
those which are obvious withoul such action. Symptoms are 
designated by the epithets, diagnostic, prognostic, and therapeu- 
tic, when they are specially applicable respectively to the distinc- 
tion, the determination of the event,and the suggestion of the 
treatmenl of disease. Symptoms are positive, when they consist 
of phenomena actually present; negative, when they consist in 



352 DIAGNOSIS OP DISEASE. 

the absence of phenomena. Of diagnostic symptoms, those are 
called pathognomonic or pathognostic, which are peculiar to one 
disease. A single symptom or sign is rarely, if ever, pathogno- 
monic; but two or three taken together often are so. 

611. The diagnosis of diseases is the distinction of diseases 
from one another. It may relate to diseases in their essential na- 
ture or pathology, or to those groups of symptoms that are classed 
as separate diseases by nosological arrangements, (§ 597.) In 
other words, the object of diagnosis is, to determine either the 
intimate nature and seat of a disease, or its name and place in a 
classification of phenomena grouped under the name of special 
diseases. According to the nosological arrangement which has 
been recommended as the best at present, (§ 600,) the division 
into special diseases is, as much as is practicable, founded on 
pathology, or the essential nature of disease; and diagnosis should 
also have a corresponding reference to this subject. But as it has 
been admitted that pathology is not sufficiently advanced to be 
the sole basis of nosology, so we must avail ourselves of other 
sources of information in regard to diagnosis. Accordingly, much 
of the materials of diagnosis are the results of simple observation 
or clinical experience; and where these cannot be analyzed by 
any more rational mode, they may be measured or valued by 
the numercial method, ox counting and calculating the results in 
a large number of cases. Thus diagnosis is chiefly derived from 
semeiology, and the results of clinical experience, arranged by 
pathology and statistics. In some instances, the causes and the 
treatment of disease give aid in the diagnosis. Thus the mala- 
rious character of a patient's residence, and the efficacy of quinine 
in curing him, will contribute important evidence as to the nature 
of his disease. 

612. Diagnosis may be general or special. General diagnosis 
comprehends the distinction between the principles or elements 
of disease, (§ 104;) as, for example, between congestion and 
inflammation; between nervous irritation and structural disease, 
&c. This is properly a branch of general pathology; and if time 
had permitted, would have been introduced here. Special diag- 
nosis relates to the distinction of diseases according to their chief 
seat, where they have one, (§ 599,) or according to some other 
specific difference, where they have no particular head-quarters. 
Thus the special diagnosis of inflammations is between inflam- 
mation of the parenchyma of an organ and that of its investing 
membrane; or between an intermittent and a continued fever. 
Special diagnosis also follows and distinguishes diseases in their 
further differences of seat or character; as the part or extent of 
a parenchyma or membrane inflamed, the type of a fever, &c. 



METHODS AND ILLUSTRATIVE PROBLEMS. 353 

Thus special diagnosis is a branch of special pathology, and should 
be aided by an accurate and practical nosological arrangement. 
The mode of distinguishing between two diseases which resem- 
ble each other has been absurdly called differential diagnosis. 
It consists in pointing out the signs which are essential to the one 
and not to the other. The signs called pathognomonic, where 
they exist, are the chief guides in differential diagnosis. 

613. The modes of investigating and distinguishing diseases 
will vary much in different cases, according to the class of symp- 
toms that first present themselves. This may be illustrated by 
the following problems: — ■ 

General pathology having pointed out the general nature of 
a disease, it is required to determine its precise seat. Example. 
In a case in which fever, hard pulse, buffed blood, and local pain 
indicate inflammation, the seat of the inflammation is determined 
by the chief place of pain or uneasiness, (in the chest or side,) by 
the function most disturbed, (difficult breathing and cough,) to 
be in the organs of respiration; by the secretion proceeding from 
the part, (rusty, viscid expectoration,) and from the physical 
signs, (impaired breath-sound and stroke-sound in part of the 
chest, with crepitant rhonchus,) to be in the parenchyma of the 
lungs; that is pneumonia. General pathology here commences 
the diagnosis, which is completed by reference to symptoms ex- 
plained by physiology and special pathology. 

Previous history, prominent symptoms, or physical signs, hav- 
ing pointed out the seat of a disease, it is required to determine 
its nature. Example. A person suffers from severe pain at the 
epigastrium; the previous occurrence of symptoms of indigestion, 
and the situation of the pain, plainly show the disorder to be 
seated in the stomach; the nature of the disease (whether nervous 
or inflammatory, &c.) is to be determined by general pathology; 
guided by this, and finding an absence of symptoms of inflam- 
mation, no increased heat of surface, no acceleration of the pulse 
further than what the pain would cause, and no increase of the 
pain on the imbibition of warm or stimulating liquids; and find- 
ing symptoms of predominant nervous properties, and the sudden 
attack, intense character, and transient duration of the pain, 
which distinguish nervous and spasmodic affections, we decide 
th.it the disease is gastralgia or gastrodynia, and not gastritis. 
The diagnosis which is begun by local symptoms is completed 
by r»'|riviii-i- to the principles of pathology. 

Lastly, which isa common case, symptoms being too few or too 
inconclusive to declare tin; diagnosis, both the seal and the nature 
of the disease are to be determined. hl.ra m/ih\ A person com- 
plains of general uneasiness, weakness, and chilliness, with va- 
rious functional symptoms, but none of a prominent character. 
30* 



354 diagnosis or DISEASE, 

Clinical experience has taught the practitioner that such are the 
symptoms of incipient fever; and he proceeds to investigate further 
the nature and cause of the fever. If he finds, on close examina- 
tion of the functions and physical condition of the different organs, 
that one is the seat of marked inflammation, and that the fever is 
not typhoid, he judges that the fever is symptomatic of the in- 
flammation; but if signs of marked local inflammation be absent, 
yet the fever continues with increasing symptoms of depression, 
weak frequent pulse, brown dry tongue, sordes on the teeth, low 
delirium, &c, he recognizes typhoid fever, resulting from the 
influence of a morbid poison on the system, (§ 105.) 

614. Thus, every department of medical knowledge is brought 
to bear on diagnosis; and in no branch is the information, as well 
as the judgment, of the practitioner more brought to a test. 
Natural shrewdness and tact, with some general knowledge of 
the nature and treatment of disease, may sometimes enable a 
comparatively ignorant person to practise medicine with an ap- 
pearance of success; but such a person can make no hand of 
diagnosis; and he wisely either evades the whole subject or ex- 
presses his opinions in vague terms, and scrupulously avoids 
their being brought to the test of the scalpel. The well-informed 
practitioner, on the other hand, feels that this is the subject which 
requires the full application of his mental powers and knowledge, 
as well as the keen exercise of his powers of observation; and in 
proportion as his senses are practised in observing, his informa- 
tion well arranged in relation to what he observes, and his judg- 
ment matured in discriminating and deciding the results, so will 
he be successful in forming his diagnosis, and in applying it to 
prognosis and practice. 

615. In investigating the symptoms of a case with a view to 
diagnosis, prognosis, and treatment, the observation is first drawn 
to those which at once declare themselves in the aspect of the 
patient, the expression of the countenance, the complexion, the 
posture, the manner of the movements, speech, &c; and these 
give important information to the observing practitioner at first 
sight and whilst he is interrogating the patient. After the first 
few statements of complaints, which are generally volunteered 
by the patient, the questions should be directed to the history of 
the ailment, including the previous state of health and habits, 
with regard to food, clothing, occupation, residence, &c, any 
former illness, the mode of the present attack, and its supposed 
cause, the former symptoms, and treatment, if any has been 
employed. The answers to these questions will direct the in- 
quiries in the most searching manner with regard to the present 
state and symptoms. The mode of investigating these will partly 
depend on the clue given by the answers to previous questions; 



\ 



INVESTIGATION OF SYMPTOMS. 355 

but the practitioner must not permit himself to be so far led by 
the patient's statements as to omit to examine the state of all the 
important organs and their functions. The nervous system and 
its functions, (sensorial, sentient, excitomotory, and sympathetic;) 
the organs of circulation and their functions, (pulse of heart 
and arteries, capillary circulation of surface and visible parts, 
temperature, state of veins, &c.;) the organs of respiration and 
their functions, (breathing, cough, expectoration, voice, arterial- 
ization of the blood;) the organs of digestion and their func- 
tions, (tongue, appetite, digestion, &c.;) the organs of secretion 
and excretion and their functions, (liver and intestines, kidneys, 
bladder, and the skin;) the functions of nutrition and assimi- 
lation, (to be judged of by the condition of the flesh and com- 
parative weight of the body;) the organs of locomotion and 
their functions; the organs of generation and their functions; 
are severally to be made the subjects of inquiry and physical ex- 
amination to such an extent as may be requisite to inform the 
practitioner of their true condition and connection with the past 
or present disease. 

The object of a complete investigation of the state of the pa- 
tient is not merely to determine the particular disease under 
which the patient labours, but to discover what is healthy as well 
as what is morbid in his condition. The prognosis, or estimation 
of the amoimt and event of the disease, and the application of 
treatment, requires this full investigation. We have to consider, 
not merely disease in the body, but the body in disease; and it 
is by losing sight of this great practical axiom, that minute or 
microscopic inquirers, who may be singularly successful in special 
diagnosis, signally fail in prognosis and in practice. 



CHAPTER VI. 



PROGNOSIS-FOREKNOWLEDGE OF THE RESULTS OF 
DISEASE. 



616. Prognosis is that knowledge by which we are enabled 
to foresee the course, duration, and event of a disease. Like the 
treatment of disease, it may be either empirical or rational. 

Empirical prognosis is that which is founded on experience or 
observation only, without regard to the nature of the disease or 
the reasons which determine the results. It consists in the obser- 
vation of the good and bad symptoms — that is, those symptoms 
which have, in a'great majority of cases, been followed respect- 
ively by a good or a bad result. This mode of prognosticating 
the events of disease was the only one attainable in the early ages 
of medicine. The " prognostics" of Hippocrates chiefly consisted 
in the enumeration of good and bad signs; and the frequent truth 
of the distinctions which he has made on these points show the 
extent and accuracy of his observation or of the sources from 
which his information was drawn. In alimited sense, the same 
faculty of empirical prognosis is often acquired by nurses or other 
non-medical attendants of the sick. These can often tell when a 
patient is getting better or worse, by the appearance of the coun- 
tenance, the state of the voice, the mind, the strength, the breath- 
ing, the excretions, &c, whilst they may be in total ignorance of 
the nature of the disease and why the signs are good or bad. 
This kind of prognostic knowledge, although it may be useful in 
enabling a person to pronounce a patient better or worse, falls far 
short of that which ought to be expected of the scientific prac- 
titioner, who should not only have a greater number of prognostic 
symptoms within his reach, but should be able to foresee them, so 
as to anticipate, and, if possible, to influence them in a favoura- 
ble manner. 

617. Rational prognosis is the estimation of the importance 
and tendencies of a disease from a knowledge of its causes, its 
true nature and symptoms, and of the power of treatment in 
regard to it. Like rational diagnosis, (§ 614,) it derives its evi- 
dence from all available sources, and makes the best use of this 



CAUSE or DISEASE. 357 

evidence by analyzing it. and thus determining its value. Thus, 
in the early stage of inflammation of the lung, the discovery of 
the nature and seat of the affection at once shows the presence of 
a serious disease, whatever may be the state of the present symp- 
toms. The practitioner, in forming a rational prognosis, takes 
into account the extent of the inflammation, knowing, from ex- 
perience as well as from reason, that this is a source of danger: 
he considers the duration of the attack, and from the signs and 
symptoms judges whether it is increasing or not. These con- 
siderations may give him some insight into the severity of the 
disease, but his prognosis is to be determined by further condi- 
tions. He knows, by experience and reason, that inflammation 
of the lungs, although always a dangerous disease, becomes much 
less so when it is at a stage and in a subject in which antiphlo- 
gistic remedies can be well borne: thus, at an early stage, in a 
young and vigorous subject, even the most extensive inflamma- 
tion may be cured by blood-letting and other means judiciously 
employed; but if the disease has advanced far, and the function 
of respiration has been for some days impaired by it; if the sub- 
ject be feeble, from infancy, or from extreme age, or from pre- 
vious disease, from intemperate habits, from a complicating 
disorder, or from any other cause, the prognosis becomes more 
unfavourable, inasmuch as there is little power in the system to 
bear the appropriate remedies, or to withstand the evil effects of 
the disease. 

To take an example of another disease. In continued fever, 
certain symptoms have been found by experience to be of an 
unfavourable character. The pathological practitioner profits by 
this experience, but he analyzes the results and goes further. He 
knows that the appearance of petechias, congested face, and stupor, 
at the commencement of fever, are bad symptoms, but that they 
are so mainly in proportion as they arise from the changed state 
of the blood induced by the depressing cause of the fever; and 
when, aa it sometimes happens, these symptoms appear without 
any corresponding depression of the heart's power, as manifest 
by extreme frequency and weakness of the pulse, they are by 
no means of such unfavourable import, but may arise from the 
plethora of the subject. Again; symptoms referable to the ex- 
citomotory system, (§ 153,) — such as subsultus, hiccup, and con- 
vulsive affections, — ;m; genera II v unfavourable in continued feverj 
but they are so only when arising from the severe operation of 
the cause of the fever on the nervous centres; they are much less 
so when occurring in a nervous subject, in whom slight causes 
may induce them. The same remark ma] be made ofa stale of 
stupor, which would he of most serious imporl if dependent on 
fever alone; bul it may be induced by slight fever, or other cause, 



35S PROGNOSIS. 

in an hysterical subject. The pathologist is prepared for these 
differences, and can qualify his prognosis accordingly. He can 
trace the danger of bad symptoms, beyond the symptoms them- 
selves, to those interferences with vital functions which renders 
these symptoms dangerous, and of which these symptoms are not 
always the true exponents. 

6 IS. As our limits do not admit of details, it must suffice to 
enumerate the chief circumstances from which a rational progno- 
sis may be formed, with illustrative examples. 

The cause of the disease. — Epidemic, endemic, and infectious 
disorders, are chiefly serious in proportion to the intensity of 
their cause. Thus the endemic of a hot climate is more dan- 
gerous than that of a cold climate: an infectious disorder propa- 
gated in close habitations is more severe, from the concentration 
of its cause, than one arising from more diluted infection. By 
knowing the source of the disease, some estimate may be formed 
of its future severity. 

519. The age of the subject. — Acute diseases are ill borne at 
either extreme of age. Acute diseases are most common in young 
and middle age. In old age, the tendency is to more chronic 
maladies. 

[In early infancy there is always hope, even with the most dan- 
gerous symptoms. " L 'enfance est Page des resurrections" says 
Chomel. It is at this period of life that the well-known adage 
ubi vita, ibi spes, is so applicable. In old age, on the contrary, 
acute diseases which assume a severe form almost always ter- 
minate fatally. In middle age the chances are more favourable, 
and are greatest in youth and adolescence. The exceptions to 
this rule are the eruptive fevers, which are less dangerous in in- 
fancy, and certain organic affections, which are said to advance 
less rapidly in old age. — C] 

The sex of the patient. — Nervous diseases are most common 
and obstinate in the female sex; but they are more serious in the 
male sex. The occurrence of the catamenia is often favourable, 
as their suppression is unfavourable in the course of a disease. 

The temperament of the patient. — In the sanguine tempera- 
ment disorders are apt to be acute; in the phlegmatic temperament, 
more chronic; and in the nervous temperament, more changeable. 

Previous diseases of the patient. — The same disease having 
occurred before, prevents or renders slight a subsequent attack, 
in the case of eruptive fevers, hooping-cough, &c; but increases 
the tendency and the danger in case of apoplexy and most struc- 
tural diseases. Albuminuria and dropsy are more curable, when 
ensuing after scarlatina, than when after other causes; but rheu- 
matism, after scarlatina and gonorrhoea, is often unusually severe 
and intractable. 



CHARACTER OF SYMPTOMS. 359 

Present diseases of the patient. — These generally increase the 
severity or intractability of the new disorder, especially if they 
be structural. Thus infectious disorders and fevers are pecu- 
liarly fatal in persons with diseased heart, lungs, kidneys, or brain. 
Yet moderate hypertrophy of the heart is rather a favourable 
circumstance in phthisis. Cutaneous and some other external 
diseases sometimes suspend attacks of gout, gravel, diarrhoea, &c. 

Previous habits of the patient. — Intemperance and excesses 
of all kinds enhance the danger of all serious attacks. Extreme 
privations, or over-fatiguing employments, make persons liable 
to fevers and other depressing diseases, and reduce the powers of 
reaction against them. 

Condition of the patient at the time of the attack. — Extreme 
weakness or exhaustion from any cause renders persons bad sub- 
jects for most diseases. Plethora increases the intensity of in- 
flammatory affections. [This statement has been shown to be 
incorrect. — C] 

[Pregnancy increases the danger of a disease supervening 
during its progress. Inflammations of the organs, and of their 
investing membranes, are very apt to pass into suppuration, and 
the exanthemata, under similar circumstances, are liable to be 
attended with ataxic and adynamic symptoms. Diseases occur- 
ring in the course of pregnancy are more severe and dangerous 
in proportion as they approach the period of confinement. — C] 

620. The situation and nature of the disease. — The more im- 
portant to life is the part attacked, and the more the disease inter- 
feres with its function, the more dangerous will it be. Thus the 
heart, the lungs, the medulla of the nervous system, and the 
blood, cannot be extensively attacked without great danger to 
life; and if the disease goes on to affect structure, as inflamma- 
tion, the danger is prolonged in proportion. 

The extent and progress of the disease. — The greater the ex- 
tent of the disease, the more serious it will be in case of inflam- 
mation; but the severity of the symptoms is often not in propor- 
tion to its extent: intense and circumscribed inflammation causing 
more prominent symptoms than that which is extensive and 
di (fused. The progress of disease most materially influences its 
effect on life and health. Thus the structure of the lungs, heart, 
kidneys, or liver, may become diseased to a most extraordinary 
amount, without destroying life, if the advance of the lesion is 
very gradual; whilst a third or fourth of the same mischief would 
prove fatal, if it were induced suddenly. 

621. The character of the symptoms. — This is exhibited in 
the details of each disease. Those symptoms augur favourably 
which show a power of moderate and regular reaction, and a re- 
turn of the functions to their natural state. The removal or 



360 PROGNOSIS. 

alleviation of the more distressing symptoms of disease — the 
restoration of the natural appetites, and feelings, bodily and men- 
tal — the return of strength — the disposition to sleeping tranquilly, 
and waking at the usual times — secretions that have been inter- 
rupted or diminished being restored, and often in increased 
quantity, as if from accumulation, as in the case of critical per- 
spirations, deposits in the urine, &c, (§ 448,) — are among the 
chief signs of approaching recovery. 

[A brief sketch of some of the most common symptoms influ- 
encing our prognosis, will not, perhaps, be here without value. 

Much may be inferred from the general aspect of the patient. 
Constant change of position, unimportant in the beginning of 
acute diseases, becomes alarming when it persists for any time. 
Lying continually in the same position, as constant dorsal decu- 
bitus, in low forms of disease, is a very bad symptom. Inability 
to lie down, which sometimes happens in thoracic disease, is 
equally sinister. Jactitation succeeding to quietude, in the latter 
stage of acute disorders, is generally a mortal sign, especially 
when accompanied by an attempt to throw aside the bed-clothes, 
and ineffectual efforts to rise. 

Progressive emaciation in acute affections is of little import- 
ance, but in chronic disorders it should lead us to anticipate a 
fatal termination in proportion to its rapidity. General oedema 
is of extremely bad augury. The occurrence of sloughs in various 
parts of the body, in both chronic and acute disorders, is a very 
bad sign. The physiognomy should be especially studied in re- 
ference to prognosis. When the natural expression of the coun- 
tenance is preserved, it is always of favourable import. Great 
alteration in the features in the commencement of an acute dis- 
order, ought to make us fear, about the fifth or ninth day, the 
supervention of low symptoms. In the advanced stage of all 
diseases, a sudden and great alteration in the physiognomy, an- 
nounces approaching dissolution. When it occurs at a period 
where a fatal termination is not to be anticipated, it should lead 
us to suspect the development of some acute affection, the en- 
feebled state of the patient not admitting of its exhibiting the or- 
dinary local symptoms; a sudden aggravation of the general 
symptoms being the only indication. It generally announces 
death in less than three days. This change of countenance must 
not be confounded with the pallor which marks the commence- 
ment of convalescence in fever, etc.; the accompanying pheno- 
mena serve to distinguish them. Subsultus, trembling, and rigidity 
always mark danger. Carphologia, epileptic and tetanic convul- 
sions, rigidity of the limbs, are mortal signs in the advanced stages 
of fever. Another invariably fatal symptom, according to Chomel, 
is the automatic movement by which the patient seeks to ap- 



CHARACTER OF SYMPTOMS. 361 

proach his hand to his body, whilst the physician is feeling his 
pulse. Aphonia is a bad sign in acute disorders. The intensity 
of pain, by no means, in general, indicates the amount of danger. 
Cceteris paribus, deep-seated pain is more unfavourable than 
that which is superficial; and that which is fixed more so than 
that which is variable. The sudden cessation of pain in in- 
flammation, joined to great alteration in the features, indicates 
approaching death. According to Chomel, suppuration not gan- 
grene will be found, under such circumstances, on examination. 
Deafness is a sympathetic phenomenon occurring in many acute 
diseases, and is always serious. In the mortality of typhoid fever, 
if a comparison be made of those who suffered from deafness in 
the course of the disease and those who did not, the deaths among 
the former will be found as two to one among the latter. (Chomel.) 
Hope and cheerfulness are generally good signs. Distrust and 
despair are very unfavourable symptoms. It is rarely that pa- 
tients who have the persuasion that they will die, recover, unless 
they are hypochondriacs. Total indifference is a bad sign. In 
several chronic disorders, the tranquil security enjoyed by patients 
does not diminish the gravity of the prognosis. 

The prognostic signs furnished by delirium are connected with 
its intensity, persistence, and the conditions under which it occurs. 
Mild delirium, soon passing off, is not serious; permanent deli- 
rium always is. Many persons, of all ages, are liable to delirium 
whenever they are attacked with ephemeral fever, or an angina; 
it is only necessary to be aware of the idiosyncrasy in order to 
appreciate the value of the symptom. 

Prolonged sleep in the course of fevers is not dangerous if the 
patient can be readily aroused. Coma is alarming and nearly 
always mortal when intense and permanent. 

The sudden occurrence of a voracious appetite announces 
speedy death, (Baglivi.) Chomel has frequently met with this 
symptom in pneumonia; death soon took place. Dysphagia is 
generally a mortal symptom in cerebral and acute disorders. 

The signs which the respiration furnishes prognosis are impor- 
tant and rarely deceive. A hurried respiration indicates great 
danger. When the number of respirations amounts to fifty in the 
hum utc, it may be generally stated that death will soon fol- 
low. The tracheal rattle and stertorous breathing are usually 
precursors of dissolution, especially when they occur towards the 
latter stages of cerebral disease. In inflammation of the lung 
stcrtor is not alarming so long as expectoration takes place. 
Paroxysmal is less dangerous than permanent dyspna3a. Hic- 
cough is a very unfavourable symptom in the latter stages of dis- 
ease, unless it is accompanied by a notable amendment in the 
other symptoms, 

31 



362 PROGNOSIS. 

The pulse furnishes few but important symptoms. A pulse of 
moderate frequency and force is favourable. Considerable fre- 
quency of pulse indicates something serious. A pulse of 150 in 
an adult should lead to a very unfavourable prognosis. If at an 
advanced period of any affection the pulse becomes irregular or 
intermittent, or ceases, death is near. 

Augmentation of the heat of the body is of bad import, espe- 
cially when dry. Sudden chilliness of the extremities and rest of 
the body occurs usually a short time previous to dissolution. 
Chills at an advanced period of the disease, should lead to the 
suspicion of the formation of pus, or of its resorption, according 
to circumstances. Abundant sweating towards the close of a dis- 
ease is a favourable sign. Cold sweats at the same period are 
generally unfavourable. 

Haemorrhages at the beginning indicate usually that the disor- 
der will be serious. Towards the close they are either favour- 
able or unfavourable. Epistaxis, the haemorrhoidal flux, and 
metorrhagia, are generally favourable signs in those who are 
liable to them. Haemorrhages from the lungs and intestines are 
usually mortal; those from the urinary organs nearly constantly 
fatal. 

The degree of strength which the patient possesses is of great 
importance in forming a prognosis; considerable diminution or 
perversion is always dangerous, especially in the early stage of 
the disease. — C] 

622. Bad or unfavourable symptoms are those which arise 
from such an impediment of one or more of the functions more 
immediately concerned in the sustenance of life, the circulation of 
the blood, respiration, nutrition, and excretion. In proportion 
as these functions are speedily and considerably impaired, life is 
threatened, and there is an approach to its destruction, by one or 
other of those terminations, which are called modes of death. 
Thus there is death by syncope — cessation of the circulation; by 
asphyxia, or apncea — interruption of the respiration; and by in- 
anition. To these may be added, death by the pernicious influ- 
ence of excrementitious matters, and by poisons, which cause 
death in various modes. These different modes of death are more 
distinct when induced so speedily as to leave the functions, which 
they do not directly affect, comparatively vigorous and outliving 
that which has been chiefly injured. Thus, in sudden death from 
causes stopping the respiration, the heart continues to act for some 
time, until the death which has begun with the breathing function 
reaches it also. 

623. If we further trace the operation of these different modes 
of death, we shall find that they all agree in affecting the blood, 



MODES OF DEATH CARDIAC SYNCOPE. 363 

either by altering its composition, or by arresting its circulation; 
and it is through one of these means that death extends to all the 
functions. Thus in death by cessation of the heart's action, the 
circulation is at once arrested; hence this is the most speedy mode 
of death. Inanition obviously operates by reducing the circulat- 
ing material, and by further weakening the organs by which the 
circulation is carried on. Asphyxia we have already found (§ 235) 
both to impede the circulation and to alter the condition of the 
blood. Excrementitious matter retained in the blood, and extra- 
neous poisons, also operate in various ways: by impairing the 
irritability of the heart; or by injuring the medullary nervous 
function, (§ 154,) on which respiration depends; or by arresting the 
passage of the blood through the capillaries, (§ 298;) or (and this 
probably includes some of the former modes) by- so changing the 
properties of the blood itself, as to render it unfit for its office of 
sustaining the life of the functions; and the operation of all poisons, 
as well as of other causes of death, may thus be traced to defect- 
ive circulation or composition of the blood. It is the more ne- 
cessary to keep these points in recollection, because they show 
why death from disease often takes place without distinctly be- 
ginning with any set of functions; but all fail from want of proper 
blood, their natural support. 

624. It will be useful to mention the chief varieties of the 
modes of death above noticed, and to state their symptoms, 
which may become available as prognostic signs of the approach 
of death. 

Death (cessation of function) beginning at the heart £ cKdnaHSXSia. 
— . — beginning at the breathing apparatus = Asphyxia or apnoca. 

— — beginning at the brain = Coma. 

— — beginning at the medulla= Paralysis. 

— — beginning in the blood =Necr3emia (nxfo;, dead,- atpa blood.) 

625. Death by cardiac syncope, or sudden cessation of the 
heart's action, may occur in two ways — 1. By this muscle losing 
its -irritability, (§ 116,) so that it ceases to contract; and 2. By 
its being affected with tonic spasm, (§ 114,) in which it remains 
rigidly contracted, losing its usual alternation of relaxation. In 
both these cases, death is quite instantaneous: the subject sud- 
denly turning pale, !';illiii'_ r back or dro|>|>iir_ r down, mid expiring 
With one gasp. In the (irsl case, both sides of ihe heart are 
found, after death, distended with blood; and if the examination 
were made soon after death, the blood in the lefl cavities would 
be found to be florid In the second case, the hearl appears smal] 
and very hard; the ventricles (or a1 leasl the left) are found so 
firmly contracted, that the cavity is almost obliterated, and con- 



364 PROGNOSIS. 

tains no blood; the muscle is very firm; but after maceration in 
water, or even without it, in two or three days, the walls of the 
ventricle yield to the pressure of the fingers, and the cavities may 
be restored to their normal dimensions. This state of the heart 
was long mistaken for concentric hypertrophy, until Cruveilhier 
and Dr. G. Budd pointed out its true nature. 

Although syncope by loss of irritability, (paralysis,) and syn- 
cope by spasm, appear to be opposite states, yet they arise from 
somewhat similar causes. In animals, wounds of the heart are 
followed sometimes by the one, sometimes by the other. Death 
by shock, as from tearing off a limb, a violent blow on the epi- 
gastrium, crushing the brain or spinal marrow, is sometimes 
caused by spasm, although more frequently by paralysis of the 
heart. In sudden death from -drinking a quantity of raw spirits, 
or of very cold water when the body is heated, the heart has been 
found contracted. 

Syncope by loss of irritability of the heart is the more common 
case; and, besides in the examples above given, it may be induced 
by the operation of large doses of certain poisons called sedative 
— such as the upas antiar, infusion of tobacco, and digitalis; and 
in combination with other effects, by large doses of hydrocyanic 
acid, strychnia, oxalic acid, arsenic, preparations of baryta, and 
various animal poisons. Mr. Blake found the power of the heart 
destroyed by solutions of various saline matters injected into the 
veins, especially salts of potass, magnesia, zinc, copper, lime, 
baryta, and lead; but these results do not correspond with what 
we find of the operation of these substances when introduced into 
the stomach. 

The diseases in which death by cardiac syncope sometimes 
takes place are — those of the heart, (but more rarely than is com- 
monly supposed;) haemorrhagic apoplexy, attended with much 
injury to the substance of the brain, (§ 364;) anaemia, (§ 270;) 
and adynamic fevers, (§105.) As it occurs suddenly, there can 
scarcely be said to be symptoms; but sometimes an approach to 
it has been manifested in previous attacks of common syncope or 
faintness, in which the action of the heart becomes weak, irregu- 
lar, and intermittent; and the partial failure of the circulation is 
evinced in the paleness of the face, lips, and general surface, often 
with cold perspiration; the failure of the sensorial functions, (de- 
fect to animi,) loss of consciousness and volition more or less 
complete, sometimes attended with various convulsive move- 
ments, (§ 153, 265;) the eyes turning up or becoming fixed or 
glazed, and the pupils dilated. The different effects of posture 
on the form of syncope have been before noticed, (§ 70;) and 
they may be presented in cases in which cardiac syncope ulti- 
mately proves fatal. The recovery from this faintness is often 



MODES OF DEATH ASTHENIA. 365 

attended with shivering, vomiting, sighing, gasping, yawning, and 
various distressing sensations of noises in the head, flashes in the 
eyes, palpitation, depression of spirits, &c; whilst the pulse re- 
gains its strength and -regularity, and the colour and warmth 
return to the surface. After this may ensue a reaction, like that 
which occurs after great losses of blood, (§ 266, 362.) 

626. Death by the gradual cessation of the heart's action 
has been termed asthenia, (a, not, odevos, strength.) This is the 
mode of termination of many diseases, especially those which 
destroy life by exhausting the strength, without any direct inter- 
ference with the more vital functions. Thus long-continued fevers, 
delirium tremens, gastritis, enteritis, peritonitis, haemorrhages, and 
various discharges of animal fluids — such as diarrhoea, diabetes, 
extensive ulcers or abscesses, &c, proving gradually fatal — in- 
anition from want of sufficient food, and several others, reduce 
the power of the heart, and with it the functions of the whole 
body, to a lower and lower state, until at last the heart flutters 
and dies. 

The symptoms of the approach of death by asthenia are — 
increasing weakness of body and mind, whilst there may be no 
marked derangement of any particular function of either; in- 
creasing frequency, and diminishing strength of the pulse; the 
face, lips, and other parts of the surface, gradually become paler 
and paler, or of a death-like sallowness; the extremities lose their 
warmth, and often become cedematous; the appetite fails; the 
tongue becomes sometimes dry and brown, sometimes furred, 
and the mouth aphthous, (§ 483;) the excretions first are im- 
perfectly voided; then the sphincters lose their power, (the weak- 
ness reaching their excitomotory function,) and involuntary dis- 
charges of urine and faeces may take place; and this state of 
sinking in a ihw hours terminates in death. The symptoms 
above described are those of progressive loss of power, not con- 
fined to the heart, but through its failure and that of the circula- 
tion of the blood, of which it is the chief instrument, becoming 
extended throughout the whole frame. But with this general 
debility there are often symptoms of partial excitement and re- 
action, which sometimes mark the sinking state. Thus a febrile 
excitement of a hectic kind (§ 471) may come on, giving slight 
temporary strength to the pulse, flush to the cheek, life to the eye, 
and a soil of flickering reanimation to the whole frame. Some- 
times the excitemenl is of a more partial land, affecting the brain, 
as wiih delirium; or the medulla, as with subsullus tendinum, 
hiccup, <>r oilier alighl convulsion; or the stomach, as with vomit- 
ing, &c. Of in the sinking state, some (unctions may become 
obscured before others, in consequence of congestions, effusions, 
or even low inflammations occurring in the capillaries of some 
31* 



386 PROGNOSIS. 

organs, (§ 290,) as the powers of the general circulation fail: 
thus the death by asthenia may become somewhat complicated 
with coma, from congestion or effusion within the head; or 
with dyspnoea, from congestion in the lungs; or somewhat simi- 
lar symptoms may arise from the early failure of the excreting 
organs, and the retention of excrementitious matter in the blood, 
(§ 249.) 

627. Asphyxia or apnoea has already been noticed as an ele- 
ment of disease, (§ 234,) and its nature and symptoms were then 
examined, (§ 235;) we here advert to it as a mode of death. By 
death beginning 1 at the breathing apparatus, I mean that in 
which the function of this apparatus is the first to fail. In this 
respect, it is distinguished from death beginning at the brain or 
medulla, which destroys by secondarily suspending the function 
of breathing. Death by simple apnoea takes place in diseases of 
the lungs and air-tubes, in which the entrance of air to the lungs 
is impeded by effusion into the air-cells or tubes; or by pressure 
upon them, as in bronchitis, pneumonia, pleurisy, &c; by obstruc- 
tion to the passage of the air through the trachea or larynx, as in 
croup, laryngitis, and tumours or spasm constricting these tubes; 
or in circumstances mechanically excluding the passage of air 
by the mouth and nostrils, as in smothering, strangling, hanging, 
and drowning. 

The symptoms of the approach of this mode of death are — 
increasing feeling of suffocation or want of breath, which becomes 
most distressing and agonizing as tbe want is unappeased; the 
efforts at respiration are made in a hurried and forced manner; 
the face, neck, and other parts of the surface become congested 
in proportion to the violence of these efforts; and as these efforts 
are unsuccessful, the colour of the congested parts changes from 
red to purple, and from purple to livid. The influence of this 
congestion and partial circulation of black blood (§ 235) is soon 
evident on the functions, causing stupor, reduction of temperature, 
weak and irregular pulse, rapid reduction of muscular strength, 
and consequently of the efforts to breathe. Hence the dark hue 
of the face may be changed for paleness; but the lividity of the 
lips, tongue, nails, and other coloured parts, remains until death. 
In cases of speedy death from violence, as hanging, drowning, 
&c, or from a sudden attack of laryngitis or spasm, the respira- 
tory efforts are more vigorous, and the congestion and lividity of 
the surface are greater, and may remain until death. But in the 
slower asphyxia from diseases of the lungs and air-tubes, the in- 
terruption to the breathing is less complete, the efforts are less 
violent, the congestion of the surface is less marked, and the func- 
tions more gradually failing together, the symptoms peculiar to 



MODES OP DEATHS-COMA. 367 

apnoea are less marked. Hence, too, as imperfectly arterialized 
blood is circulated throughout the body, it may cause peculiar 
symptoms, such as stupor and low delirium, partial paralysis, 
vomiting, relaxation of the sphincters, and other symptoms of 
sinking. This exemplifies what has been before remarked, 
(§ 622,) that the distinctness of each mode of death generally 
depends on its speedy supervention. 

As prognostic signs, the symptoms of apnosa are more hope- 
less in proportion as they are conjoined with those of debility. 
The nature of the obstruction to the respiration must of neces- 
sity be taken into account; and if this be not complete and irre- 
movable, the congestion and lividity of the surface are not fatal 
signs, so long as the strength of the breathing apparatus and of 
the heart does not decline; as this becomes exhausted the means 
of recovery are lost. 

628. Death by coma, or beginning at the brain, is caused by 
various influences which primarily destroy the functions of the 
superior masses of the nervous system. The chief of these cir- 
cumstances are — obstruction to the circulation through the brain 
by pressure, (as of eflused blood, pus, lymph, or serum, or of dis- 
tended vessels in apoplexy, a depressed portion of bone in frac- 
tured skull, &c.;) by coagula within the vessels, (§ 267;) by 
anasmia, (§ 267;) and by various narcotic poisons, such as opium, 
alcohol in large quantities, carbonic acid inhaled, (§ 246,) and 
sometimes the excrementitious matter of urine and of bile in the 
blood, (§ 249.) 

The symptoms of coma are those of interrupted function of the 
brain, insensibility and suspension of voluntary motion, the heart's 
action not being materially impaired. These may come on in 
different modes. In apoplexy and injuries of the head they may 
supervene suddenly, and the patient at once becomes powerless 
and senseless, the pulse continues pretty good, although slower 
and fuller than usual, or it may be frequent from mere sympathy. 
In other cases, the stupor conies on gradually, and the senses 
and mental powers are often irregularly obscured, causing dim- 
ness of sight, appearances of clouds or cobwebs before the eyes, 
muscx volit antes; various imperfections of hearing, with noises, 
or tinnitus uurium; numbness and tingling sensations in the 
limbs; loss of memory, confusion of ideas, hallucinations, low 
delirium alternated with stupor, (typhomaniu,) continued somno- 
lency, &c. Partial paralysis often accompanies progressively ad- 
vancing coma, sometimes of the lower extremities, (paraplegia^ 
more commonly of one side, [hemiplegia.) In the operation oJ 
narcotics, the state of coma is commonly preceded by symptoms 
of cerebral excitement, manifest in the usual signs of intoxication 



368 PROGNOSIS 

and delirium, which vary in the case of different poisons. For 
these particulars, I must refer to works on toxicology and materia 
medica. 

In conjunction with these symptoms, referable to the sensorial 
and voluntary functions, there are often symptoms of various 
affections of the excitomotory system of the medulla; at first they 
are those of excitement, such as convulsion, vomiting, hiccup, 
contracted pupil, &c. (§ 152.) Thus, the coma of apoplexy, and 
sometimes the stupor of narcotism, are occasionally accompanied 
by convulsions, (§ 150,) general or local; and I have elsewhere 
(§ 153) endeavoured to explain how these opposite effects on 
different parts of the nervous centres may arise from the same 
cause. But in cases of more extreme coma, the excitomotory 
power of involuntary motions becomes impaired, the breathing 
is stertorous and imperfect, the actions of coughing and expecto- 
ration are not easily excited, deglutition becomes impossible, the 
pupils are dilated, emetics fail to excite vomiting, the sphincters 
are relaxed, and involuntary discharges of urine and faeces take 
place. This last group of symptoms was before noticed as the 
fatal part of coma and narcotism, (§ 154.) 

It is a question whether the functions of the brain can be com- 
pletely suspended for any length of time without those of the 
medulla suffering also. During sleep there is not complete insen- 
sibility or suspension of volition, for movements are then made 
in consequence of unpleasant sensations, yet without the sleep 
being broken. It is probable that in the trance of nervous sub- 
jects, of hysteric coma, (§ 141,) either sensation or volition is not 
entirely abolished; but it is difficult to ascertain the truth in these 
cases, for the patients often deceive themselves as well as others. 
But in the heavy sleep of intoxication, and in the stupor of coma, in 
which pinching scarcely excites any evidence of consciousness, the 
functions of the medulla seem to be also impaired, for the breath- 
ing is slow and stertorous, and irritations of the nose and eyes less 
readily than usual excite the motions of sneezing and winking. 
It is in proportion as these functions are impaired that coma be- 
comes dangerous; and it is because they are not materially 
impaired in nervous or hysteric stupor, that this is unattended 
with danger. It appears probable, however, that coma, when 
complete, may cause death by the abolition of sensation only. 
Although the movements of breathing are ordinarily independent 
of the consciousness or will, yet such is not the case of the extra- 
ordinary movements which commonly take place in a deep breath 
or sighing, when the ordinary action is impeded by posture, 
fatigue, or any other cause. A sensation of want of breath 
is then felt, and an effort is made to relieve that sensation. But 
when sensibility and voluntary power are suspended, these 



MODES OF DEATH PARALYSIS. 369 

supplementary efforts are not made; for want of them, the respi- 
ration may be insufficiently performed, and the lungs may be- 
come congested; this congestion further impairs the involuntary 
part of the process of respiration, and the symptoms and effects 
of apnoea are gradually induced. Under such circumstances, it 
is of great importance to place the patient in such postures or 
other circumstances, as shall most favour the movements of breath- 
ing, and to remove pulmonary congestion by the proper reme- 
dies, should it arise. 

Snoring arises from a relaxed state of the soft palate, and is of 
little moment so long as the movements of breathing are suffi- 
ciently strong and frequent; but when the respiratory powers 
are impaired, stertor is not only a sign but a cause of obstruction 
to the passage of the air, and" should be prevented as much as 
possible by changing the posture of the patient. 

The most dangerous kind of coma, then, is that attended with 
symptoms of impaired excitomotory function, these symptoms 
being apparent especially in connection with respiration. In 
apoplexy, contraction of the pupil of one or both eyes is of very 
unfavourable import, because it indicates an excitement of the 
upper portion of the medulla, whilst the brain is oppressed; such 
a combination can only proceed from the partial operation of a 
clot in the substance of nervous centres, compressing one part 
and irritating another. 

629. That death should ensue from injured function of the 
medulla oblongata and spinalis is quite intelligible, when it is 
considered fhat on this portion of the nervous system the ordinary 
act of breathing depends. This mode of death, like the last, is 
by apnoea; but the death, or failure of function, here begins with 
the nervous link of the chain of actions constituting the process 
of respiration, whereas, in simple apnoea, it commences with the 
mechanism of the breathing apparatus. 

This death may be called death by paralysis, and as in other 
cases of paralysis of an excitomotory function, (§ 144,) it may be 
caused by suspended function, cither of the nervous centre, 
(medulla oblongata,) or of the afferent nerves, (par vagum and 
sympathetic,) or of the efferent, nerves, (phrenic, intercostals, and 
spinal accessory,) which complete the respiratory circle. Of in- 
fluences which destroy the function of the medulla oblongata 
itself, may be mentioned, haemorrh.-u.'ie ell'usion into its substance 
or upon it. fractures of the base of the skull, and any irery consi- 
derable pressure on the whole encephalon. Some poisons seem 
to affect the medulla more ii i m m ■* I i:t i< I \ ilnn the brain. Thus, 
animals poisoned with woorara, essential oil of bitter almonds, 
conia, belladonna, and perhaps some other poisons, are affected 



370 PROGNOSIS. 

with gaspings and other signs of impaired function of respira- 
tion before they lose consciousness; according to the experiments 
of Sir 13. Brodie and others, they die simply from suspension of 
respiration, and if this process be artificially maintained for a 
time, the animals may sometimes recover from the effects of the 
poison. The same remark in some degree apples to opium and 
its active principle, but less distinctly, for these early induce coma, 
and often impair the action of the heart also. Experiments are 
wanting to establish the elementary operation of this and other 
poisons, as the functions are now viewed by physiologists. In 
some cases in which I have seen animals die from rapid haemor- 
rhage, the respiration has ceased for some seconds before the 
heart's action; and from the peculiarly laboured state of the 
breathing, and late retention of consciousness, I conclude, that 
death from haemorrhage, in some instances at least, is due to sus- 
pension of the function of the medulla. 

630. The division of the eighth nerves in the neck in animals 
illustrates one mode of inducing death by paralysis. These are 
the chief incident or afferent nerves from the lungs to the medulla, 
transmitting the impressions which excite the motory nerves of 
the muscles of respiration. When they are divided, the breathing 
is imperfectly performed, and expectoration and cough cannot 
take place; apnoea, therefore, gradually follows. Although we 
have not a result to the same amount exhibited in disease, yet 
we have an approach to it in the dyspnoea, sometimes constant, 
sometimes in paroxysms, caused by pressure of tumours on these 
nerves, or by malignant disease involving them. 

631. The third mode in which the nervous link of respiration 
may be broken, injury to the excitomotory column of the spinal 
marrow or its branches, is exemplified in the case of breaking 
the neck, or dislocation of the upper cervical vertebrae. Pithing 
an animal effects the same thing. All parts supplied by nerves 
from below the injured portion of the medulla become paralyzed, 
and therefore their motions cease. Diseases in the vertebrae, in 
the spinal cord, or in its membranes, have been followed by simi- 
lar results; and the functions of the several nerves of respiration 
are illustrated by these cases. I have known disease affecting the 
cord at the upper cervical vertebrae cause loss of motion in all 
parts below the neck except the diaphragm, which is supplied by 
the phrenic nerve, and through which for a while respiration was 
wholly carried on. The patient afterwards regained power in 
the spinal accessory nerve, by which he was enabled to elevate 
the upper part of the chest; and subsequently some power was 
for a time restored to the superior intercostal nerves and muscles.* 

* Med. Chir. Trans., 1843. 



MODES OF DEATH MEDULLARY PARALYSIS. 371 

In other cases, disease of the spinal cord creeps from below up- 
wards, beginning with paralysis of the lower extremities and 
pelvis, then reaching the dorsal spine, palsying the intercostals, 
and at last reaching the neck. The advance or retrogression of 
all these symptoms are of great importance in the prognosis of 
such diseases. 

632. Besides the respiratory function, the functions connected 
with excretion are dependent, on the integrity of the spinal cord; 
they fail when it is seriously injured, and this failure may furnish 
symptoms of death beginning at the spinal cord. When the cord 
is injured only at a point, and remains healthy above and below 
it, the injury may merely intercept the transmission of sensation 
upwards, or of volition downwards, beyond the injured point. 
Hence, there may be loss of sensation, or of voluntary motion, 
or of both, in the lower portions of the body. If this reach the 
urinary apparatus, the power of spontaneously voiding urine is 
lost. But the reflex or independent excitomotory influence of the 
spinal cord remains; hence, the sphincters and the bladder retain 
their power, and when the catheter is introduced into the bladder, 
it contracts as usual, aided by the voluntary power remaining in 
the diaphragm and abdominal muscles. We have before noticed, 
(§149,) that under these circumstances the muscles of the lower 
extremities retain and accumulate their irritability, and although 
the will has no command over them, yet tickling, or even touch- 
ing them, may excite them to contract. The exercise thus kept 
up seems to be sufficient to preserve their nutrition, for they do 
not waste away. 

But it is quite different if the spinal cord be extensively injured, 
as by crushing, softening, or a considerable effusion of blood or 
pus into its shgpth. Its function then ceases, not only as a com- 
municator of sensation and voluntary power to the lower parts 
of the body, but also as a source of that involuntary excitomotory 
power by which the sphincters contract and the urinary bladder 
evacuates its contents. Hence, there is constant dribbling of 
urine, yet without the power completely to empty the bladder. 
The faeces are discharged unconsciously, and without the power 
of control. The limbs are not only insensible and powerless to 
the will, but their muscles can no longer be excited by tickling. 
they lose all motion, and the blood-vessels lose that, influence 
which the nerves of all orders exercise upon them. It is not sur- 
prising, under such circumstances, that the death which has begun 
in the spina] cord should spread to the parts whose functions it 
crni in. Longer maintain, The mine, imperfectly discharged, pu- 
trefies, and causes inflammation of the bladder, which may gra- 
dually extend to and stop the (unction of the kidneys. The intes- 
tines become distended and obstructed with gas and pent up faxes. 



372 PROGNOSIS. 

The limbs lose their proper circulation for want of motion and 
nervous influence on their muscles and vessels; their nutrition 
fails, they become oedematous, partially inflamed, livid, and run 
into gangrene; and all these changes are so many signs of the 
progress of death which has begun in the spinal cord. 

From the remarkable effect of cold and some poisons on some 
of the lower animals, inducing paralysis of the hinder extremities, 
it is probable that these agents are capable of especially injuring 
the function of the spinal cord, beginning with the remote part. 
Has the gangrene of the lower extremities, sometimes induced by 
the use of ergotted corn, any connection with an injured function 
of the spinal cord? 

Death of the medulla supervenes on that beginning with coma 
and asthenia in many cases; and as its involuntary excitomotory 
function is the guardian of many processes essential to life, the 
symptoms connected with it are of great importance in connection 
with prognosis. 

633. NecaBmia, or death beginning with the blood, are terms 
which I venture to give to those fatal cases in which the first and 
most remarkable change is exhibited by the blood. In typhoid 
fevers and others of the malignant or pestilential kind, none of 
the solids of the body constantly exhibit such an early change of 
function or of structure as would warrant us in tracing disease 
and death to them. It is true, that the functions of many solids 
are impaired — the muscular and nervous systems, secretion, 
digestion, assimilation, and nutrition, all suffer, but the very uni- 
versality of the affection seems itself to point to some cause 
more general than can be found in any individual function; and 
such a cause may be found in the blood. The bl^pd, at an early 
period of these diseases, when they occur in their worst form, 
exhibits changes which show that disorder begins with it, and 
this disorder may reach to a fatal degree. The appearance of 
petechias and vibices on the external surface, the occurrence of 
more extensive haemorrhages in internal parts, the general flu- 
idity of the blood, and frequently its unusually dark or otherwise 
altered aspect, its poisonous properties as exhibited in its dele- 
terious operation on other animals, (§ 258,) and its proneness 
to pass into decomposition, point out the blood as the first seat 
of disorder, and by the failure of its natural properties and offices 
as the vivifier of all structure and function, (§ 180, 262,) it is 
plainly the medium by which death begins in the body. How 
far the change in the blood is in its structure (§ 189) and vital 
properties, (§ 201,) or in its chemical composition, (§ 182,) fur- 
ther research alone can determine; the vivifying function of the 
blood depends on all these combined, and it is this function which 



MODES OF DEATH NECR^MIA-. 373 

obviously fails. Hence the complete adynamia, or general pros- 
tration of all living powers, which occurs where this cause of 
death is most powerful. The blood, the natural source of life to 
the whole body, is itself dead, and spreads death instead of life. 
Almost simultaneously, the heart loses its power, the pulse be- 
coming very weak, frequent, and unsteady: the vessels lose their 
tone, especially the capillaries of the most vascular organs, and 
congestions occur to a great amount, (§ 290, 293,) the brain be- 
comes inactive, and stupor ensues; the medulla is torpid, and the 
powers of respiration and excretion are imperfect; voluntary 
motion is almost suspended; secretions fail; molecular nutrition 
ceases; and at a rate much more early than in other modes of 
death, molecular death follows close on soynutic death — that is, 
structures die and begin to run into decomposition as soon as the 
pulse and breath have ceased, nay, a partial change of this kind 
may even precede the death of the whole body, (somatic death — 
Dr. Prichard,*) and parts running into gangrene, as in the car- 
buncle of plague, the sphacelous throat of malignant scarlatina, 
and the sloughy sores of the worst forms of typhus, or the putrid 
odour exhaled even before death by the bodies of those who are 
the victims of similar pestilential diseases, are so many proofs of 
the early triumph of dead over vital chemistry. 

634. We have hitherto represented an extreme case; but there 
are many lower degrees in which disease begins with the blood, 
and various disturbances and reactions result. The causes which 
appear thus primarily to affect the blood are especially endemic, 
epidemic, and infectious influences, called poisons, (§ 81, 88, 93,) 
certain animal and vegetable poisons, as that of the most venom- 
ous reptiles and fungi, and probably some mineral poisons, as 
sulphuretted hydrogen, selenium, and, in part of its operation, 
arsenic. The direct influence of all these agents is depress- 
ing, (§ 105,) and when they operate in large quantities, or in a 
concentrated form, the vital powers fall quickly into a state of 
adynamia or prostration, which soon ends in death, as we have 
already described it, the blood first and most constantly manifest- 
ing a change. But if the noxious influence is in smaller quan- 
tity, or more diluted, the vital powers react against it (lfi) in 
various ways, the object of which can often be plainly discerned 
to be its expulsion from the system. The shivering, hoi stage, 
and sweating termination of |>;n-oxysms of intermittent fever; the 
similar but Less marked-series of. febrile movements which occur 
in slight forms ofremittenl and continued fevers; the profuse and 
violenl fluxes from the stomach ami intestines in cholera, dysen- 
tery, and epidemic diarrhosa, and the similar < I ischiums induced 

' • See Or. Symond's interesting essay on " Death," in the Cyclopaedia of Ana- 
tomy and l'hysiology. 
32 



374 FROGNOSIS. 

by poisonous ingesta, are instances of the operation of vital re- 
action attempting the expulsion of the noxious matter and of that 
part of the animal fluids that had been corrupted by it. But 
these struggles in many instances constitute serious diseases, in 
which life may be compromised by the violence and exhausting 
effect of the reaction as much as by the prostrating influence of 
the cause of the disease; and in these more complex affections, 
individual organs may especially suffer in different cases, and the 
danger and the cause of death may be less in the changed con- 
dition of the blood than in the affections of particular organs, or 
the exhaustion consequent upon them, which destroy, not by 
necreemia, but by coma, asphyxia, or asthenia, modes of death 
already considered. 

635. But the injurious effect of these poisons maybe still more 
completely prevented when their quantity is small and the living 
powers are vigorous. A diarrhsea, a profuse sweat, or a free 
flow of urine, sometimes carries off the commencing disease. 
The intestines, the skin, and the kidneys, appear to be the proper 
emunctories through which morbid matter is expelled. The 
peculiar fetor of the secretions from the bowels in typhoid fever, 
and the beneficial influence of moderate diarrhoea, which removes 
them in the early stage of fever, seem to be an example of the 
elimination of a morbific matter; and I have before suggested 
(§ 404, note,) that the follicular inflammation and ulceration of 
the intestines in fever may arise from the excessive irritation of 
the follicles in the exercise of this eliminating function. Again, 
with regard to the kidneys, it has been before mentioned, that 
granular degeneration, which impairs their function, renders the 
body peculiarly liable to contract epidemic and infectious dis- 
eases, and to succumb under them, (§ 260.)* This renders the 
prognosis unusually unfavourable in these cases. The same 
remark extends, and for the same reasons, to persons who have 
been habitually intemperate. On the other hand, those whose 
kidneys are naturally active more effectually resist disease, and 
more readily throw off its effects, (§ 448.) In like maimer, it 
is well known that persons with a naturally dry skin do not so 
readily get rid of a fever as those in whom perspiration is readily 
excited. 

636. Besides the extrinsic influences already mentioned, (§ 634,) 
as first attacking the blood,and in extreme cases injuring its com- 
position, and causing its death, there are others originating in 

* This has been exemplified in the case of an epidemic erysipelatous angina, 
which attacked several patients of the University College Hospital last spring, 
(1843.) Out of about a dozen cases in which persons affected with various dis- 
eases were attacked, three died from the erysipelas extending to the larynx, and 
in all these the kidneys were granular and the urine albuminous. 



MODES OF DEATH EQUAL DEATH. 375 

the body itself. Thus the processes of gangrene and suppuration 
sometimes infect the blood with a septic poison, (§ 470, 475,) and 
cause death in a manner and with symptoms like those of the 
poisons above noticed. The sudden suppression of the excre- 
tions of urine or bile, from disease, or under the influence of any 
severe shock, also' seem in some cases to operate by injuring the 
properties of the blood; whilst in other instances it distinctly 
induces coma or asthenia. We have before adverted to retention 
of excrementitious matter as a cause of cac/tzemia, or depraved 
state of the blood, (§ 249, 564;) so we now find that, in an extreme 
degree, it may cause necrsemia, or death of the blood. 

637. The symptoms which should make us apprehend the 
approach of death by necroemia may be gathered from the pre- 
ceding descriptions. Those symptoms generally called typhoid, 
putrid, or malignant, belong especially to this class of death. 
For example: a congested appearance of the whole surface, the 
colour being dusky or livid, and extending to the conjunctivas, 
tongue, and fauces; various, slight, exanthematous, or papular 
patches on the skin, often with petechiae; more extensive haemor- 
rhages in form of ecchymoses, or oozing of thin bloody fluid from 
the gums, nostrils, and sometimes from other passages; extreme 
prostration of strength, with an obtuse state of all the senses and 
mental faculties, sometimes combined with delirium and twitch- 
ings of the limbs; half-closed eyes and dilated pupils; a very fre-< 
quent, weak, and soft pulse; frequent and unequal respiration; 
no appetite; intense thirst; a dry, brown tongue, with dark sordes 
on the lips and teeth; a progressive fall of temperature, which 
may have been elevated at first; often cold, clammy, and foetid 
perspiration; hiccup; subsultus tendinum; scanty, offensive urine; 
involuntary discharges. 

Some diseases of the same class are modified by peculiar effects. 
Thus in malignant cholera, excessive discharges of serum, by 
vomiting and by stool, reduce the blood to such a spissitude, that 
it will no longer circulate through the vessels; the pulse ceases, 

and the surf; heroines blue and cold from the darkness and 

stagnation of the blood, and shrunk from the exhaustion of its 
fluids. In yellow fever, altered blood is ejected from the stomach 
in the form of what is called black vomit. Jhit to pursue this 
subjeel into further details belongs rather to the department of 
special pathology. 

638. It has been before mentioned, thai the complete distinc- 
tion of these different modes of death is almost exclusively con- 
fine. I foe ises of speedy or sudden death. In the slower dissolution, 
by which diseases generally prove fatal, all functions and struc- 



376 PROGNOSIS. 

tures are more or less involved; and the life in all is dwindled 
down to so slight a thread, that when it breaks in one, others 
scarcely retain it long enough to enable us to say that death 
begins distinctly in any part. 



CHAPTER VII. 



PROPHYLAXIS AND HYGIENICS. 

639. Prophylaxis is the guarding against a particular disease; 
and hygienics relate to the prevention of diseases in general, or 
the preservation of health. The former is appropriately con- 
nected with special pathology; and it should be founded on a due 
knowledge of the causes, nature, and tendencies of diseases, and 
of the various means in diet, regimen, residence, and medicine, 
which are capable of removing the causes of disease, or of pre- 
venting or counteracting their operation. 

640. Hygienics consist in the knowledge and application of 
those means, by which the structures and functions of the body 
may be kept in that normal state which conduces to their con- 
tinued welfare — that is, in health, (§6.) We have found, that 
both structures and functions have the elements of disease in 
themselves, when any thing disturbs their due proportion. We 
have noticed the circumstances which lead to such disturbance, 
both in connection with the causes of disease, (under the head 
Etiology,) and in connection with its intimate nature, (in the 
division Pathology proper;) and remarks on the means of pre- 
venting or counteracting those circumstances were introduced in 
the context to a sufficient extent to suggest the principles of 
hygienics. Want of time prevents me from introducing here, as 
I had intended to do, — 1. A brief review of the chief causes of 
disease, for the sake of pointing out the means of preventing 
their occurrence, or resisting their operation; and, 2. A short ac- 
count of those circumstances which most promote the healthy 
condition in the several functions and structures of the body. 

[641. The object of hygiene is the preservation of health and 
the prevention of disease; and hygienics include every thing 
which lends lo accomplish these ends. Although hygiene has 
been called the medicine of healthy individuals, it is still applica- 
ble and even indispensable to invalids, and is often of more ser- 
vice to them than medicine itself; for whilst the efficacy of many 
remedies may be doubtful, the propriety of hygienic measures is 
universally admitted, liy their aid alone, without a resort to the 
32* 



378 PROPHYLAXIS AND HYGIENICS. 

materia medica, the majority of acute disorders will terminate 
favourably; without them our best directed efforts will often prove 
unavailing. We frequently see patients in bad hygienic con- 
ditions, perish in spite of able physicians, and an abundance of 
remedies, and the mildest diseases converted into mortal ones from 
similar reasons. The crowding of patients into narrow, ill-ven- 
tilated places, the contamination of the air, the absence of cleanli- 
ness, the want of suitable clothing, exposure to cold and wet, 
errors of diet, mental depression, fatigue, collectively, invariably, 
produce terrible effects; whilst in a large number of acute affec- 
tions of the severest kind, recovery occurs without a resort to 
any active remedy, merely under general hygienic measures. 

642. Wherever the conditions most favourable to the develop- 
ment and preservation of the health of the body, are most com- 
pletely fulfilled, in the same proportion do we find least sickness 
and mortality. Millions annually perish from a neglect of the con- 
ditions which a Divine Wisdom has appointed as requisite for the 
protection of the body from disease; and millions more are in a 
state of perpetual suffering and pain from simple inattention to 
the common principles of hygiene. From the moment of birth the 
infant is almost entirely dependent upon the condition in which 
it is placed, for the future development of its frame. The due 
supply of warmth, food and air, are the principal points to be 
attended to in the care of infant life; and on every one of them 
the greatest errors of management prevail. Thousands of infants 
annually perish from exposure to cold in the first few days of in- 
fancy, and subsequently from inattention to simple physiological 
principles which should regulate the amount of their clothing in ac- 
cordance with the condition of the medium by which they are sur- 
rounded. Another source of injury is the constant transgression of 
the rules of diet, both as to quantity and quality, and inattention to 
the maintenance of a due supply of fresh and wholesome air. It is 
impossible for human beings to grow up in a sound and healthy 
state of body and mind, in the midst of a close, ill-ventilated 
atmosphere. Those who are the least able to resist its influence, 
die in infancy and childhood; whilst those who possess naturally 
more vigour of constitution, become enfeebled, and have their 
life prematurely cut off by disease, or are deprived of the en- 
joyment and blessings of health, dependent on a sound consti- 
tution. (Carpenter's Animal Physiology, p. 3.) 

643. The work-houses of London, about a century ago, pre- 
sented the astounding result of 23 deaths in every 24 infants, 
under one year of age. When an improved system of manage- 
ment was adopted, the proportion of deaths was speedily reduced 
from 2600 to 450, in a year. Here was an annual loss of 2150 
lives, chargeable to ignorance, indifference or cruelty. At the 



PROPHYLAXIS AND HYGIENICS. 379 

present day, every tenth infant perishes within a month of its 
birth.* 

644. In the island of St. Kilda, 8 out of every 10 children die 
between the eighth and twelfth day of their existence. This 
alarming mortality is due not to the operation of any noxious in- 
fluence in the position or atmosphere of the island, but solely to 
the filth in which the inhabitants live, and the effluvia which 
pervade their houses. The clergyman, who lives in all other re- 
spects but in the condition of his house, as those around him, has 
reared a family of four healthy children. In a lying-in institution 
in Dublin, at the conclusion of 1782, out of 17,650 children born 
alive, 2944, or nearly every sixth child, died within a fortnight. 
By the employment of additional means of ventilation the mor- 
tality was speedily reduced to only 419 out of 8033, or 1 in 19^, 
instead of 1 in 6; and it has recently been still further diminished. 
The following statement of the comparative number of deaths 
of children under five years of age, in London, during successive 
periods of 20 years, is additional proof of the benefit derived 
from increased attention to hygienic measures. In the 20 years 
subsequently to 1730, out of every 100 children born, 74£, or 
nearly 3 out of 4, died before they were five years old. In the 
succeeding 20 years, the proportion of deaths was reduced to 63 
in 100, or less than two-thirds. Between 1770 and 1790, it was 
only 51 £ in 100, or little more than one-half. In the 20 years 
succeeding 1790, it was further reduced to 41 \ in 100, or little 
more than two-fifths. And between 1810 and 1830 it was no 
more than 32 in 100, or less than one-third.t 

645. The health of the adult suffers scarcely less from excesses 
in mental or bodily labour, sensual indulgence, or from privation 
of the conditions essential to life — warmth, food, and air. A 
great improvement has taken place in the duration of human 
adult life from increased attention to hygienics. The average 
duration of life among the ancient Romans, when compared with 
that of the English of the present day, was as two to three. With- 
in the last hundred years the term of human life has undergone a 
considerable increase. But much yet remains to be done by which 
further improvement may result. The mortality in France, and 
probably in the whole civilized world, is more than twice as great 
among the poor in numerical proportion, than amongst the classes 
in easy circumstances. 

646. By ;i reference to the chief causes of disease, (chap. l,sect. 
II,) we shall ascertain the requisite conditions necessary to the pre- 
servation of health; ;my departure from them is almost certain to 
entail serious consequences. 

• Dr. A. Combe on the Physiological and Moral Management of Infancy, 
j- Carpenter, loc. cit. 



380 PROPHYLAXIS AND HYGIENICS. 

647. The annual slaughter in England and Wales from preventi- 
ble causes of typhus which attacks persons in the vigour of life, ap- 
pears to be double in amount to what was suffered by the allied 
armies in the battle of Waterloo. The higher mortality of English 
women by consumption may be ascribed partly to the in-door 
lives they lead, and partly to the compression preventing the ex- 
pansion of the air by costume. 31,090 English women die in 
one year of this incurable malady, (Letter to the Registrar Gene- 
ral, p. 73, 1841.) The daughters of the poorer classes are deprived 
of that vital air, and free exercise, without which the circulation 
becomes languid and the blood vitiated, when as dress-makers 
they are confined all day and a portion of the night in crowded, 
ill-ventilated apartments. " It is not doubted," says Mr. Chad- 
wick, " by medical witnesses that one-third at least of the health- 
ful duration of adult life amongst milliners, dress-makers, and 
tailors, will be found to be destroyed by ignorance of the want of 
ventilation." The health of girls in the higher classes is sacrificed 
" to those eternal accomplishments, which, with small benefit to 
the intellect and none to the feelings, inevitably dwarf and dwin- 
dle the body, and too often lay the beauteous fabric in the dust. 
Many hours to music, many to drawing, many to fancy-work, 

ome to languages, and few — but very few — to exercise in the 
open air 'wear through the longest day.' When exercise is taken 
it is often in some public walk, under the superintendance of 
some silly and ignorant governess, by whom every ebullition 
natural and healthful to youth — the jocund laugh, the run and the 
leap — are repressed as ungenteel — that stupid and vulgar word 
to which so much of the health and happiness of youth is sacri- 
ficed. In an education calculated to draw forth the powers of 
the mind and body all should be vigorously done. But this is 
overlooked in female education. During the long hours of les- 
sons in drawing, music, &c, the attention becomes languid, the 
mind weary, objects impress it feebly, and much of the time that 
is thus literally wasted would be infinitely much more usefully 
spent in play. A shorter period of vigorous study and a longer 
one of bodily exertion of a different kind from what we have 
witnessed and endeavoured to describe, would send young ladies 
forth to the world from their homes or seminaries of education at 
once better instructed and more healthful than we now see 
them." 

648. The pernicious influence of a dense population on the 
diseases of the respiratory apparatus is unequivocally proved. The 
close and foul air of the cotton mills and other manufactories is 
a powerful cause of consumption, the respiration of a deteriorated 
atmosphere rapidly inducing the tuberculous cachexia, as Sir 
James Clarke tells us. 



PROPHYLAXIS AND HYGIENICS. 381 

649. Insufficient arid ill-proportioned diet is another constant 
cause of disease. Observation and experiment have fully proved 
the absolute necessity of considerable variety of food for the pre- 
servation of health and life, (§ 58.) Experience demonstrates 
that the aliment of man must be presented to him in a variety of 
forms, and must not be restricted to the vegetable kingdom alone. 
It was formerly supposed that scurvy, a disease of nutrition, was 
only produced by the use of salt provisions, but it is now found 
to be engendered by restriction to any one kind of diet. Scurvy 
frequently attacks the Indian of South America, who lives almost 
on rice alone. It has reigned epidemically in the rice grounds 
of Lombardy and Piedmont. The same disease prevailed in an 
epidemic form in Germany in 1771 and 1772, years of scarcity, 
■when many of the inhabitants were obliged to live on legumes, 
roots, and even the bark of trees. Scurvy affected numbers of the 
poor people in France in 1S12, 1816, 1817, when even wild 
plants were employed as food in consequence of scarcity. How 
far typhus, scarlet fever, and other epidemics of large towns, are 
affected by an imperfect nutriment is an interesting subject for 
inquiry. 

650. Exercise is another hygienic measure of the first import- 
ance. Walking, progressively increasing the amount, is an ex- 
cellent restorative. Horseback exercise has been much and justly 
lauded by Sydenham. A cheerful companion is indispensable in 
walking. " Languor will at first ensue, but, as this goes off, an 
exhilarating glow pervades the frame, ending in cheerfulness, 
craving appetite, and if properly persevered in, complete restora- 
tion of all the excretions." (McCormac.) A patient may ride one 
day, and walk the next; it is often useful to alternate active with 
passive exercise. 

651. Attention to the moral condition of the patient should 
not be overlooked. Entire change of scene and occupation is 
often alone sufficient to renovate health, and effect an entire 
recovery. With students the mental must not be cultivated to the 
prejudice of the corporeal powers. The morning is a better time 
than night for study; and if intense, it should be followed by exer- 
cise in the open air. 

652. A lev/ i_ r encral rules on the hygienics of sick persons will 
not inappropriately close this chapter. 

Patients labouring under acute disorders should be placed 
in large, dry and well ventilated apartments. The temperature 
of the room should be equable and moderate; the amount of light 
must be regulated by the character of the disease. When the 
air is contaminated by noisome exhalations, fumigations may 
sometimes be advantageously resorted to. If the room in which 
the patienl is taken ill be small, badly ventilated or damp, he 



3S2 PROPHYLAXIS AND HYGIENICS. 

should be removed, if possible, into a larger one, free from these 
inconveniences, as the risks of moving, even in severe febrile af- 
fections, are less than is usually imagined. (Chomel.) 

653. Great cleanliness should be strictly maintained, and for 
this purpose the linen should be frequently changed; but not so 
as to fatigue the patient. It may be done even whilst the patient 
is sweating copiously, and great comfort will result. To eiFect 
this, warm cloths, passed underneath the shirt, should envelop 
successively the legs, thighs, abdomen, chest, and even the neck, 
so that the arms alone will be momentarily exposed to the air. 
Patients should never be permitted to sleep on feather beds, 
without an intervening mattrass. It is often necessary to employ 
auxiliary means to receive the excretions, impermeable cloths to 
protect the bed linen, and cushions to obviate pressure on certain 
parts of the body. The position of the bed should vary according 
to the nature of the disease. 

654. The employment of suitable aliments and drinks in acute 
affections is of great importance, and adds materially to the com- 
fort of the patient. There are two extremes to be equally avoided; 
nourishing patients too much, and not nourishing them enough. 
Hippocrates thought it safer to err on the side of excess, than for 
patients to observe total abstinence. In acute febrile affections, 
you should observe a just medium. Proscribe all kinds of solid 
aliment, but permit the use of fluids slightly nutritious, such 
as the farinaceous articles, light broths of veal and chicken, the 
juicy fruits, etc., when the febrile movement is not too high. In 
the low forms of fever, when the strength has to be supported, it 
is indispensable to nourish the patient, and severe adynamic 
symptoms may often be prevented by timely nourishment. The 
injudicious use of food has the power, it has been remarked by 
a celebrated authority, of nourishing the disease, and not the 
patient. 

655. It is of immense importance in all acute disorders that the 
excretions of the patient should be immediately removed. Per- 
spiration chills the body; the urine and fecal matter, already com- 
promised, are disposed to speedy decomposition, and impart 
noxious qualities to the air. When involuntarily excreted their 
contact with the body is positively injurious, by provoking erup- 
tions, excretions, and even sloughing. 

656. In acute diseases, repose and quiet are indispensable. 
Sydenham thought that fever patients should be made to rise 
every day, and that doing so obviated the tendency to delirium. 
There is no doubt but that patients should be daily placed in an 
arm chair, or on a bed, according to their strength, in order to 
allow their own bed to be made; if this cannot be done they can 
be removed to another portion of their bed, whilst the necessary 



PROPHYLAXIS AND HYGIENICS. 383 

change is made. When a patient is too feeble to change his 
position in bed, it should be done for him frequently; it adds 
materially to his comfort, prevents the formation of sloughs, and 
obviates the tendency to pulmonary congestion, so frequent in 
protracted fevers. 

657. Sleep is generally a favourable symptom in acute dis- 
eases. Every thing which by acting on the senses, or the moral 
of the patient will prevent it, should be obviated. From the same 
motives sleep should not be broken to administer medicines, 
without the necessity is urgent. Sleep may sometimes be in- 
duced in convalescence, by causing the patient to rise, and re- 
adjusting his bed. Gentle friction with the fingers on some part 
of the body disposes to somnolency. 

658. The sensations, the emotions and intellectual faculties all 
demand, in a special manner, the attention of the physician. The 
removal of all moral or mental circumstances, which either have 
produced or keep up the morbid condition, is important. Con- 
versation should be banished from the sick chamber; when low 
it is annoying; when loud, fatiguing and exciting. The in- 
fluence of the passions of the mind are so great that nothing 
should be neglected to give them a favourable turn. To this end 
the physician should obtain and deserve the confidence of the 
patient, (careful attention and great interest will frequently ac- 
complish this,) and he should be careful that nothing in his man- 
ner or speech should betray anxiety or uneasiness. Patients 
generally receive with satisfaction assurances of the successful 
termination of their complaint from their physician. The fear of 
death adds materially to the danger, in a majority of instances, 
and "the physician," says Chomel, "who allows his patient to 
suspect the danger of his position diminishes his prospects of re- 
covery." Sir H. Halford, in some judicious remarks on the duty 
of a physician, in withholding from, or communicating to, a pa- 
tient the probable issue of a disease displaying mortal symptoms, 
says, "that the first duty of a physician is, to protract the life of 
a patient by all practical means. 7 ' The probability of a fatal 
issue should, therefore, be communicated to the friends, and, ex- 
pepl under very peculiar circumstances, never to the patient. 

659. In chronic diseases, hygienics are of immense utility. 
Change of habitation and climate, voyages by land and sea, a 
sojourn :it some fashionable watering place, &c. 3 often succeed in 
restoring health when all other remedial measures have failed. 

• Lond. Med. Gaz., vol. vii., p. C02. C] 



THE END. 






*9 > 



>■ jg> 



y>>io >*>■. > ^>> 



» i> ,o 



* , > 5 >< > > ■ «&. 

> > ))> 3>>SJ 



>.*> ' »>"> >> »>> 



33 






-3 »> 






3 VV^ov 






m la? ^4? 






^ 3 












>>> * S> >> *>!-> . ? ?', 












%*> 5 



> > > 
> > > 
) > ^ 

> > > 



^^?.? 



> » 



> > > > > ^* 



